Diarrhea in children under 5 years of age from Ifakara, Tanzania: a case-control study

Social and Environmental Determinants of Diarrheal Diseases among Children under Five Years in Epworth Township, Harare

Children five years or younger in low- and middle-income countries (LMICs) are severely affected by diarrheal disease, especially in the sub-Saharan region. Hence, this study aimed at determining the prevalence and determinants of diarrhoea disease among children under 5 years in Epworth Township, Zimbabwe. A descriptive cross-sectional study was conducted at a local clinic in Epworth Township, Harare. A convenience sampling strategy was used to recruit study participants for participation, and 386 children were enrolled in the study. The majority were male children (n = 229; 59.3%), whereas there were more female caregivers (n = 370; 95.9%) than male caregivers (n = 16; 4.1%). The prevalence of diarrhoea disease in the study was 25.1%. The determinants associated with diarrhoea were being partially vaccinated (AOR 2.38, CI: 95% 2.80-8.22), collecting water more than 1 kilometre from a household (AOR 4.55; CI: 95% 2.10-9.85), and using untreated water (AOR 6.22; CI: 95% 2.13-18.20). The age of the caregiver (being older than 21) and using a clean water container (AOR 0.05; CI: 95% 0.02-0.13) were protective factors. Provision of primary health care, especially the prevention of a disease through immunization and rendering environmental health services, could reduce the prevalence of diarrhoea in disadvantaged townships.

Comparative Analysis of Human and Animal E. coli: Serotyping, Antimicrobial Resistance, and Virulence Gene Profiling

Widespread multidrug-resistant (MDR) and multi-virulent diarrheagenic E. coli create several crises among human and animal populations worldwide. For this reason, we looked forward to a breakthrough with this issue and tried to highlight these emerging threats. A total of 140 diarrheagenic E. coli isolates were recovered from animal and human sources. The O26 serotype, alongside the ampicillin/cefoxitin resistance phenotype, was predominant among both human and animal isolates. Of note, imipenem represented the most effective antibiotic against all the investigated isolates. Unfortunately, 90% and 57.9% of the tested isolates showed MDR and multi-virulent patterns, respectively. The animal isolates were more virulent and showed higher sensitivity to antimicrobial agents. Both animal and human isolates could not be arranged into related clusters. A strong negative correlation between the existence of virulence genes and antimicrobial resistance was clearly detected. A significant correlation between serotypes and antimicrobial resistance was not detected; meanwhile, a significant positive correlation between some serotypes and the presence of certain virulence genes was announced. Finally, our results confirmed the urgent need for restricted guidelines, in addition to new alternative therapies, due to the genetic diversity and wide spreading of MDR side by side with multi-virulent E. coli isolates.

Global Prevalence of Yersinia enterocolitica in Cases of Gastroenteritis: A Systematic Review and Meta-Analysis

The prevalence of Yersinia enterocolitica in gastroenteritis is often underestimated. It relates considerably to morbidity and medical expenses around the world. Understanding the cause of gastroenteritis leads to making the appropriate treatment decisions. We systematically searched PubMed, Science Direct, Embase, and Scopus to identify all published studies between Jan. 1, 2000, and Dec. 31, 2019, to assess the prevalence of Y. enterocolitica in gastroenteritis patients. A total of 5039 articles were identified that lead to the extraction of data from 47 of them. The pooled prevalence of Y. enterocolitica in cases of gastroenteritis was estimated as 1.97% (1.32–2.74%) in the culture method and 2.41% (1.07–4.22%) in the molecular method. Among the biotypes of Y. enterocolitica, 1A (62.48%) and 1B (2.14%) had the most and least prevalence, respectively. Serotype O3 Y. enterocolitica with 39.46% had the highest and O5,27 with 0.0% had the least prevalence in gastroenteritis cases. In conclusion, the findings of this systematic review show that Y. enterocolitica is prevalent in gastroenteritis in all age groups. Serotypes O3 and O9 of Y. enterocolitica had the highest prevalence and O5,27 had the least prevalence in diarrheal patients. The prevalence of Y. enterocolitica was similar in both gender and different seasons. It should be noted that to determine the role of the organism, more studies are needed especially in food-borne diseases.

Associated factors, post infection child growth, and household cost of invasive enteritis among under 5 children in Bangladesh

Both Campylobacter- and Shigella-induced invasive enteritis are common in under-5 Bangladeshi children. Our study aimed to determine the factors associated with Campylobacter and Shigella enteritis among under-5 children, the post-infection worsening growth, and the household cost of invasive enteritis. Data of children having Shigella (591/803) and Campylobacter (246/1148) isolated from the fecal specimen in Bangladesh were extracted from the Global Enteric Multicenter Study (GEMS) for the period December 2007 to March 2011. In multiple logistic regression analysis, fever was observed more frequently among shigellosis cases [adjusted OR 2.21; (95% CI 1.58, 3.09)]. Breastfeeding [aOR 0.55; (95% CI 0.37, 0.81)] was found to be protective against Shigella. The generalized estimating equations multivariable model identified a negative association between Shigella and weight-for-height z score [aOR − 0.11; (95% CI − 0.21, − 0.001)]; a positive association between symptomatic Campylobacter and weight-for-age z score [aOR 0.22; (95% CI 0.06, 0.37)] and weight-for-height z score [aOR 0.22; (95% CI 0.08, 0.37)]. Total costs incurred by households were more in shigellosis children than Campylobacter-induced enteritis ($4.27 vs. $3.49). Households with low-level maternal education tended to incur less cost in case of their shigellosis children. Our findings underscore the need for preventive strategies targeting Shigella infection, which could potentially reduce the disease burden, associated household costs, and child growth faltering.

Pathogens associated with acute diarrhea, and comorbidity with malaria among children under five years old in rural Burkina Faso

INTRODUCTION

acute diarrhea in children under five years is a public health problem in developing countries and particularly in malaria-endemic areas where both diseases co-exist. The present study examined the etiology of childhood diarrhea and its comorbidity with malaria in a rural area of Burkina Faso.

METHODS

conventional culture techniques, direct stools examination, and viruses´ detection by rapid tests were performed on the fresh stools and microscopy was used to diagnose malaria. Some risk factors were also assessed.

RESULTS

on a total of 191 samples collected, at least one pathogen was identified in 89 cases (46.6%). The proportions of pathogens found on the 89 positive stool samples were parasites 51.69% (46 cases), viruses 39.33% (35 cases), and bacteria 14.61% (13 cases), respectively. The relationship between malaria and infectious diarrhea was significant in viral and parasites causes (p=0.005 and 0.043 respectively). Fever, vomiting and abdominal pain were the major symptoms associated with diarrhea, with 71.51%, 31.72% and 23.66% respectively. The highest viral diarrhea prevalence was reported during the dry season (OR=5.29, 95% CI: 1.74 - 16.07, p=0.001) while parasite diarrhea was more encountered during the rainy season (OR=0.41, 95% CI: 0.33 - 0.87, p=0.011).

CONCLUSION

Giardia spp and rotavirus were the leading cause of acute diarrhea in Nanoro, Burkina Faso with a predominance of rotavirus in children less than 2 years. Parasite and viral diarrhea were the most pathogens associated with malaria. However, the high rate of negative stool samples suggests the need to determine other enteric microorganisms.

Burden of Shigella spp and Vibrio spp, and their antibiotic sensitivity pattern in the patients with acute gastroenteritis in tertiary care hospital in Nepal

Objectives

The present study aims to investigate the etiology, clinical profile and resistance pattern of the isolated pathogens in Nepalese adults with acute gastroenteritis. This cross-sectional study was conducted at Sukraraj Tropical and Infectious Disease Hospital, from April 2016 to Sep 2017. Subjects’ ages 14 or above, presenting with gastroenteritis with positive stool culture were enrolled for analysis.

Results

Of total 153 patients, 47.72% subjects confirmed the presence of bacterial infection. Vibrio cholerae spp and Shigella spp were detected in 36.6% and 23.28% respectively. The most common resistance among Vibrio cholerae was to nitrofurantoin (92.8%), cotrimoxazole (92.8%) and nalidixic acid (92.8%). Among 17 isolates of Shigella spp, the most frequent drug resistant was observed in ampicillin (64.7%), nalidixic acid (58.8%), ceftriaxone (47%). Chloramphenicol (94.1%), tetracycline (88.2%), and cotrimoxazole (82.3%) were found to be the most sensitive towards this pathogen. High rate of diarrhea due to bacterial infection, especially Shigella spp and Vibrio spp and their high rate of drug resistance emphasize an urgent need of designing a surveillance system for antimicrobial resistance in Nepalese setting.

EAST1 toxin: An enigmatic molecule associated with sporadic episodes of diarrhea in humans and animals

EAST1 is produced by a subset of enteroaggregative Escherichia coli strains. This toxin is a 38-amino acid peptide of 4100 Da. It shares 50% homology with the enterotoxic domain of STa and interacts with the same receptor. The mechanism of action of EAST1is proposed to be identical to that of STa eliciting a cGMP increase. EAST1 is associated with diarrheal disease in Man and various animal species including cattle and swine. Nevertheless, as EAST1-positive strains as well as culture supernatants did not provoke unequivocally diarrhea either in animal models or in human volunteers, the role of this toxin in disease is today still debated. This review intent is to examine the role of EAST1 toxin in diarrheal illnesses.

Prevalence and determinants of diarrhea among under-five children in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Despite remarkable progress in the reduction of under-five mortality, childhood diarrhea is still the leading cause of mortality and morbidity in this highly susceptible and vulnerable population. In Ethiopia, study findings regarding prevalence and determinants of diarrhea amongst under-five children have been inconsistent. Therefore, this systematic review and meta-analysis estimates the pooled prevalence of diarrhea and its determinants among under-five children in Ethiopia.

METHODS

International databases, including PubMed, Web of Science, EMBASE, CINAHL, Google Scholar, Science Direct, and the Cochrane Library, were systematically searched. All identified observational studies reporting the prevalence and determinants of diarrhea among under-five children in Ethiopia were included. Two authors independently extracted all necessary data using a standardized data extraction format. STATA Version 13 statistical software was used. The Cochrane Q test statistics and I2 test were used to assess the heterogeneity of the studies. A random effects model was computed to estimate the pooled prevalence of diarrhea. Moreover, the associations between determinant factors and childhood diarrhea were examined using the random effect model.

RESULTS

After reviewing of 535 studies, 31studies fulfilled the inclusion criteria and were included in the meta-analysis. The findings from the 31 studies revealed that the pooled prevalence of diarrhea among under-five children in Ethiopia was 22% (95%CI: 19, 25%). Subgroup analysis of this study revealed that the highest prevalence was observed in Afar region (27%), followed by Somali and Dire Dawa regions (26%), then Addis Abeba (24%). Lack of maternal education (OR: 2.5, 95% CI: 1.3, 2.1), lack of availability of latrine (OR: 2.0, 95%CI: 1.3, 3.2), urban residence (OR: 1.9, 95%CI: 1.2, 3.0), and maternal hand washing (OR: 2.2, 95%CI: 2.0, 2.6) were significantly associated with childhood diarrhea.

CONCLUSION

In this study, diarrhea among under-five children in Ethiopia was significantly high. Lack of maternal education, lack of availability of latrine, urban residence, and lack of maternal hand washing were significantly associated with childhood diarrhea.

Determinants of childhood diarrhea in Medebay Zana District, Northwest Tigray, Ethiopia: a community based unmatched case-control study

Background

Globally, childhood diarrhea is amongst the most prevalent health problems and accounts for 9% of all deaths in children under-five. In Ethiopia, childhood diarrhea is a major public health problem in which the prevalence ranges from 13.5 to 30.5% and experienced by multiple factors. Although health extension program has been implementing for couples of years; diarrheal disease remains the second cause of morbidity and continues an important public health problem in the study district. Thus, this study assessed determinants of diarrheal disease among under-five children in the Medebay Zana district, northwest Tigray, Ethiopia, 2015.

Method

A community based case-control study was used. A multistage sampling procedure was employed to enroll the study participants. Data were collected using face to face administered questionnaire. The collected data were entered into Epi Info version 3.5.4 and exported to SPSS Version 21 for analysis. Frequencies with percentages were computed using univariate analysis. Finally, logistic regression model was fitted to identify factors associated with childhood diarrhea where P-values of less than 0.05 were considered statistically significant.

Results

Socio-demographic factors such as low maternal educational level [AOR = 2.88, 95% CI (1.70, 4.88)], being index child of older age, households with ≥3 number of children under-five [AOR = 4.05, 95% CI (1.91, 8.60)] and maternal history of diarrhea [AOR = 2.10, 95% CI (1.09, 4.05)] were statistically associated with childhood diarrhea. This study also revealed that child feeding practice; not exclusively breastfed [AOR = 4.84, 95% CI (2.21, 10.60)] and initiation of complementary feeding above 6 months [AOR = 1.78, 95% CI (1.09, 2.92)] were statistically associated with outcome variable. Environmental and behavioral practices such as unavailability toilet facility [AOR = 2.10, 95% CI (1.34, 3.30)], improper solid waste disposal [AOR = 2.29, 95% CI (1.53, 3.44)] and unprotected drinking water [AOR = 1.83, 95% CI (1.12, 2.98)] were also found significant factors of childhood diarrhea.

Conclusion

Maternal educational status, age of index child, number of < 5 children, child feeding practices, maternal history of diarrhea, toilet facility, solid waste disposal and household drinking water were found determinants of childhood diarrhea. These findings have policy implications and insight the strengthening for health intervention programs.

The impact of the Boko Haram insurgency in Northeast Nigeria on childhood wasting: a double-difference study

BACKGROUND

This research examines the relationship between violent conflict and childhood wasting in Northeast Nigeria, where residents have been subjected to fighting between the Nigerian government and Boko Haram - an extremist Islamist movement - since 2009.

METHODS

Using two Demographic and Health Surveys from before and after the Boko Haram insurgency started, a double-difference (difference-in-difference) approach is used to assess the impact of the conflict on mean weight-for-height z-scores and the likelihood of wasting.

RESULTS

Results suggest that if children exposed to the conflict had not been exposed, their mean weight-for-height z-score would be 0.49 standard deviations higher (p < 0.001) than it is, increasing from - 0.74 to - 0.25. Additionally, the likelihood of wasting would be 13 percentage points lower (mean z-statistic - 4.2), bringing the proportion down from 23% to 10%.

CONCLUSION

Descriptive evidence suggests that poor child health outcomes in the conflict areas of Northeast Nigeria may be due to disruptions to social services and increased food insecurity in an already resource poor area. Although other unidentified factors may contribute to both conflict and wasting, the findings underscore the importance of appropriate programs and policies to support children in conflict zones.

Influence of Water, Sanitation, and Hygiene Practices on Common Infections among Under-Five Children in Longido and Monduli Districts of Arusha, Tanzania

The study aimed at assessing water, sanitation, and hygiene practices and their influence on infectious diseases among under-five children in semipastoral communities of Arusha. The study was cross-sectional in design. Prevalence of infectious diseases among under-five children was derived from patients' attendance register. Mothers randomly sampled from households were interviewed using questionnaire. Information regarding child morbidity and sociodemographic and WASH characteristics was gathered. Hospital data revealed that 2/3 of under-five patients visited the hospitals annually were suffering from infectious diseases. Mean percentage of diarrhea prevalence for years 2013–2015 in Longido was higher than the mean of the respective years prevalence in Monduli (p = 0.02). Households' survey showed that 15.5% of under-five children were suffering from diarrhea. Children who consumed foods kept in kibuyu (p < 0.001) or used unboiled cows' milk (p = 0.01) or were drinking surface water (p = 0.04) or born to uneducated mothers (p = 0.01) had increased risk of developing diarrhea compared to their counterparts. Storing complementary foods in kibuyu was strongly associated with diarrhea among under-five children. To address the problem, communities under study need to be motivated through health education on food hygiene, proper handling of food storage containers, and domestic water treatment at the household level.

Longitudinal Comparison of Antibiotic Resistance in Diarrheagenic and Non-pathogenic Escherichia coli from Young Tanzanian Children

Enteroaggregative, enteropathogenic, and enterotoxigenic Escherichia coli contribute significantly to the burden of diarrheal infections particularly in developing countries. Antibiotic resistance is increasingly common among bacterial pathogens including pathogenic E. coli. We assessed the relationship between pathogenic E. coli carriage and resistance to six antibiotics in E. coli isolated from young children in rural Tanzania. We surveyed temporal stability in antibiotic resistance in 2492 E. coli isolated from fecal samples obtained from young children in rural Tanzania collected over a 6 months period. Approximately half of the 377 children sampled were exposed to an azithromycin mass treatment program for trachoma control and half resided in control villages. Children were sampled at baseline, 1-, 3-, and 6 months following azithromycin treatment. We compared resistance to six antibiotics in pathogenic and non-pathogenic strains at the population level, within fecal specimens, and within individuals over time using chi-square tests, paired odds ratios, and logistic regression, respectively. Resistance to ampicillin and trimethoprim/sulfamethoxazole was highly prevalent (>65%). Resistance to 5 of 6 antibiotics tested and multi-drug resistance occurred more frequently in pathogenic isolates (p ≤ 0.001) within fecal specimens and overall. Azithromycin mass treatment exposure was significantly associated with increased odds of carriage of isolates resistant to erythromycin (OR 3.64, p < 0.001) and trimethoprim/sulfamethoxazole (OR 1.60, p < 0.05). Pathogenic isolates were approximately twice as likely to be resistant to erythromycin, ampicillin, or trimethoprim/sulfamethoxazole compared to non-pathogenic isolates from the same fecal specimen. The potential linkage between resistance and virulence in E. coli suggests hygiene and sanitation interventions aimed at reducing disease burden could play a role in controlling transmission of antibiotic resistance.

High occurrence of Blastocystis sp. subtypes 1-3 and Giardia intestinalis assemblage B among patients in Zanzibar, Tanzania

BACKGROUND

Blastocystis is a common intestinal parasite with worldwide distribution but the distribution of Blastocystis and its subtypes in East Africa is largely unknown. In this study, we investigate the distribution of Blastocystis subtypes in Zanzibar, Tanzania and report the prevalence of intestinal parasites using both molecular methods and microscopy.

METHODS

Stool samples were collected from both diarrhoeic and non-diarrhoeic outpatients in Zanzibar. In addition to microscopy, real-time PCR for Blastocystis, Entamoeba histolytica and E. dispar, Giardia intestinalis, Cryptosporidium spp., and Dientamoeba fragilis was used. Blastocystis subtypes were determined by a conventional PCR followed by partial sequencing of the SSU-rRNA gene. Genetic assemblages of Giardia were determined by PCR with assemblage specific primers.

RESULTS

Intestinal parasites were detected in 85 % of the 174 participants, with two or more parasites present in 56 %. Blastocystis sp. and Giardia intestinalis were the most common parasites, identified by PCR in 61 and 53 % of the stool samples respectively, but no correlation between carriage of Blastocystis and Giardia was found. The Blastocystis subtype distribution was ST1 34.0 %, ST2 26.4 %, ST3 25.5 %, ST7 0.9 %, and 13.2 % were positive only by qPCR (non-typable). The Giardia genetic assemblages identified were A 6.5 %, B 85 %, A + B 4.3 %, and non-typable 4.3 %. The detection rate with microscopy was substantially lower than with PCR, 20 % for Blastocystis and 13.8 % for Giardia. The prevalence of Blastocystis increased significantly with age while Giardia was most prevalent in children two to five years old. No correlation between diarrhoea and the identification of Giardia, Blastocystis, or their respective genetic subtypes could be shown and, as a possible indication of parasite load, the mean cycle threshold values in the qPCR for Giardia were equal in diarrhoeic and non-diarrhoeic patients.

CONCLUSIONS

Carriage of intestinal parasites was very common in the studied population in Zanzibar. The most commonly detected parasites, Blastocystis and Giardia, had different age distributions, possibly indicating differences in transmission routes, immunity, and/or other host factors for these two species. In the Blastocystis subtype analysis ST1-3 were common, but ST4, a subtype quite common in Europe, was completely absent, corroborating the geographical differences in subtype distributions previously reported.

High Prevalence of Diarrheagenic Escherichia coli among Children with Diarrhea in Kenya

Diarrheagenic Escherichia coli (DEC) is an important agent of endemic and epidemic diarrhea worldwide, particularly in developing countries. DEC cannot be differentiated from commensal E. coli on selective media, although there are a few exceptions. Most studies use the colony isolation method, which cannot detect low numbers of DEC, and therefore, these studies might underestimate the incidence of DEC. In the present study, we employed a colony sweep method with real-time PCR targeting virulence genes of 5 categories of DEC; this technique can detect very low numbers of DEC among hundreds of commensal E. coli. DEC was detected in 171 (55.9%) of 306 children with diarrhea in Kenya. The prevalence of DEC in Kenya was notably higher than that (30 in 143, 21.0%) in Indonesia. Occurrences of multiple DEC infection in Kenya were frequent (69 in 306, 23.2%), suggesting that the source of DEC infection may be related to grossly contaminated food and water. In contrast, only 9 (6.0%) of 150 healthy adults in Kenya carried DEC. Considering that healthy adults naturally harbor non-DEC, it is interesting how children exclude DEC but not non-DEC as they grow up. Several mechanisms, such as mucosal immunity and intestinal microbiota, might be involved in the exclusion of DEC.

Detection of enterotoxigenic E. coli in hospitalised children with and without diarrhoea in Blantyre, Malawi

BACKGROUND

Enterotoxigenic E. coli (ETEC) is an important cause of diarrhoea among children in developing countries. The burden of ETEC infection was investigated for the first time in children in Malawi.

METHODS

Faecal samples obtained from children < 5 years of age hospitalised with diarrhoea in Blantyre, Malawi over a 10-year period (1997-2007) before introduction of the rotavirus vaccine were examined by PCR for ETEC heat-labile (LT) and heat-stable (STh and STp) enterotoxins. Children hospitalised without diarrhoea were enrolled over a 2-year period as a comparison group.

RESULTS

ETEC was detected in 205 (10.6%) of 1941 children with diarrhoea. The most prevalent toxin type was STh (6·6%), followed by LT (2·1%) and STp (0·9%). ETEC infection was most prevalent in infants aged 6-11 months. Co-infection with rotavirus was common. ETEC was detected in 37 (7·3%) of 507 children without diarrhoea.

CONCLUSION

The burden of ETEC infection in young Malawian children is substantial and should become a focus of diarrhoea prevention efforts in the post-rotavirus vaccine era.

Risk Factors for Sporadic Infection With Campylobacter Spp. Among Children in Israel: A Case-control Study

BACKGROUND

Campylobacter spp. has been identified as one of the leading causes of bacterial gastroenteritis in the world. In recent years, an increase in the incidence of campylobacteriosis in several countries, including Israel, was demonstrated. The incidence rate of campylobacteriosis in Israel increased from 22.3 per 100,000 in 1997 to 77.4 per 100,000 in 2009. The aim of this study was to explore risk factors for sporadic infection with Campylobacter among young children in Israel.

METHODS

A matched case-control study was performed to investigate risk factors for sporadic Campylobacter infection among 113 affected children of 1-5 years of age and 113 age-matched, gender-matched and neighborhood-matched controls. Information about exposure to potential risk factors was obtained via telephone interview and was evaluated by conditional logistic regression analysis.

RESULTS

In the multivariable model, for each additional chicken meal consumed during the week before the onset of illness, the odds for Campylobacter infection increased by 32% [adjusted matched odds ratios (aMOR): 1.32; 95% confidence interval (CI): 1.01-1.72; P = 0.04], whereas consumption of fruits and vegetables decreased the odds for Campylobacter infection by 97% (aMOR: 0.03; 95% CI: 0.00-0.28; P < 0.01), and for each additional child living in the household, the odds for infection decreased by 48% (aMOR: 0.52; 95% CI: 0.33-0.83; P < 0.01). Using diaper increased the odds for campylobacteriosis (aMOR: 7.36; 95% CI: 1.66-32.70; P < 0.01).

CONCLUSIONS

Interventions that focus on proper handling of chicken and chicken products, hand washing and encouraging consumption of fruits and vegetables could help in controlling Campylobacter infections.

Child Health in the Peruvian Amazon: Prevalence and Factors Associated with Referred Morbidity and Health Care Access in the City of Iñapari

Introduction. Children under 5 years of age are more susceptible to developing morbidities such as diarrhea, respiratory infections, anemia, and malnutrition. The objective of the study is to evaluate the prevalence of reported morbidities in this age group in the city of Iñapari (Peru) and the access to health services in this municipality. Methods. Data collection using interviews that assessed socioeconomic and demographic conditions, child morbidity, and access to health services was performed in 2011. Statistical analysis was performed using SPSS 13.0. Results. Regarding morbidities that occurred during lifetime, 39.8% reported previous anemia and intestinal parasite infection. About 53.7% of the children reported any type of morbidities in the last 15 days before interview, being most frequent respiratory symptoms (38.9%), diarrhea (23,4%), and fever (23,1%). Only 63.1% of those reporting recent morbidities sought health care. These morbidities were associated with precarious sanitation and lack of infrastructure, the presence of other comorbidities, and poor access to health services. Conclusion. The main referred morbidities in Amazonian Peruvian children were diarrhea, respiratory symptoms, anemia, and vomiting. Incentives and improvements in the health and sanitation conditions would be important measures to improve the quality of life of the Amazonian child population.

Water use practices, water quality, and households' diarrheal encounters in communities along the Boro-Thamalakane-Boteti river system, Northern Botswana

BACKGROUND

Some rural African communities residing along rivers use the untreated river water for domestic purposes, making them vulnerable to waterborne diseases such as diarrhea.

METHODS

We determined water use practices and water quality, relating them to prevalence of diarrhea in communities along the Boro-Thamalakane-Boteti river system, northern Botswana. A total of 452 households were interviewed and 196 water samples collected show during February, May, September, and December 2012 in settlements of Boro, Maun, Xobe, Samedupi, Chanoga, and Motopi. Information was sought on water use practices (collection, storage, and handling) and diarrheal experience using questionnaires. Water quality was assessed for physicochemical and microbiological parameters using portable field meters and laboratory analysis, respectively.

RESULTS

All (100%) of the river water samples collected were fecally contaminated and unsuitable for domestic use without prior treatment. Samples had Escherichia coli (E.coli) and fecal streptococci levels reaching up to 186 and 140 CFU/100 ml, respectively. Study revealed high dependence on the fecally contaminated river water with low uptake of water treatment techniques. Up to 48% of households indicated that they experience diarrhea, with most cases occurring during the early flooding season (May). Nonetheless, there was no significant relationship between river water quality and households' diarrheal experience across studied settlements (p > 0.05). Failure to treat river water before use was a significant predictor of diarrhea (p = 0.028).

CONCLUSIONS

Even though the river water was unsafe for domestic use, results imply further recontamination of water at household level highlighting the need for simple and affordable household water treatment techniques.

Prevalence of Cryptosporidium parvum/hominis, Entamoeba histolytica and Giardia lamblia among Young Children with and without Diarrhea in Dar es Salaam, Tanzania

Background

Although enteroparasites are common causes of diarrheal illness, few studies have been performed among children in Tanzania. This study aimed to investigate the prevalence of Cryptosporidium parvum/hominis, Entamoeba histolytica and Giardia lamblia among young children in Dar es Salaam, Tanzania, and identify risk factors for infection.

Methodology/Principal Findings

We performed an unmatched case-control study among children < 2 years of age in Dar es Salaam, recruited from August 2010 to July 2011. Detection and identification of protozoans were done by PCR techniques on DNA from stool specimens from 701 cases of children admitted due to diarrhea at the three study hospitals, and 558 controls of children with no history of diarrhea during the last month prior to enrollment. The prevalence of C. parvum/hominis was 10.4% (84.7% C. hominis), and that of G. lamblia 4.6%. E. histolytica was not detected. The prevalence of Cryptosporidium was significantly higher in cases (16.3%) than in controls (3.1%; P < 0.001; OR = 6.2; 95% CI: 3.7–10.4). G. lamblia was significantly more prevalent in controls (6.1%) than in cases (3.4%; P = 0.027; OR = 1.8; 95% CI: 1.1–3.1). Cryptosporidium infection was found more often in HIV-positive (24.2%) than in HIV-negative children (3.9%; P < 0.001; OR = 7.9; 95% CI: 3.1–20.5), and was also associated with rainfall (P < 0.001; OR = 2.41; 95% CI: 1.5–3.8). Among cases, stunted children had significantly higher risk of being infected with Cryptosporidium (P = 0.011; OR = 2.12; 95% CI: 1.2–3.8). G. lamblia infection was more prevalent in the cool season (P = 0.004; OR = 2.2; 95% CI: 1.3–3.8), and more frequent among cases aged > 12 months (P = 0.003; OR = 3.5; 95% CI: 1.5–7.8). Among children aged 7–12 months, those who were breastfed had lower prevalence of G. lamblia infection than those who had been weaned (P = 0.012).

Conclusions

Cryptosporidium infection is common among young Tanzanian children with diarrhea, particularly those living with HIV, and infection is more frequent during the rainy season. G. lamblia is frequently implicated in asymptomatic infections, but rarely causes overt diarrheal illness, and its prevalence increases with age.

Diarrheal diseases are a leading cause of disease and deaths among young children. In Africa they contribute to more than one tenth of childhood deaths. Parasites like Cryptosporidium, Entamoeba histolytica and Giardia lamblia are all common causes of diarrheal illness, but there are few studies on these enteroparasites among Tanzanian children. In this case-control study, we included 701 cases and 558 controls, all < 2 years of age, in Dar es Salaam, Tanzania. We assessed the prevalence of C. parvum/hominis, E. histolytica and G. lamblia by PCR, and the association with potential risk factors such as demographic data, clinical symptoms, HIV status and seasonality. One or more parasites were found in 14.9% of the samples. C. parvum/ hominis and G. lamblia were found in 10.4% and 4.6%, respectively, while E. histolytica was not found in any of the samples. The prevalence of Cryptosporidium was high, particularly in children with HIV, and its prevalence increased during the rainy season. Among cases, Cryptosporidium was found more frequently in stunted children, although any causal association could not be established in the current study. G. lamblia was more often implicated in asymptomatic infections than in overt diarrheal illness. The prevalence of G. lamblia increased with age, and breastfeeding seemed to protect the children from G. lamblia. This study presents relevant information about the prevalence and clinical characteristics of these intestinal parasites in Tanzanian children.

Enteropathogens associated with acute diarrhea in children from households with high socioeconomic level in uruguay

Infectious diarrhea, a common disease of children, deserves permanent monitoring in all social groups. To know the etiology and clinical manifestations of acute diarrhea in children up to 5 years of age from high socioeconomic level households, we conducted a descriptive, microbiological, and clinical study. Stools from 59 children with acute community-acquired diarrhea were examined, and their parents were interviewed concerning symptoms and signs. Rotavirus, adenovirus, and norovirus were detected by commercially available qualitative immunochromatographic lateral flow rapid tests. Salmonella, Campylobacter, Yersinia, and Shigella were investigated by standard bacteriological methods and diarrheagenic E. coli by PCR assays. We identified a potential enteric pathogen in 30 children. The most frequent causes of diarrhea were enteropathogenic E. coli (EPEC), viruses, Campylobacter, Salmonella, and Shiga-toxin-producing E. coli (STEC). Only 2 patients showed mixed infections. Our data suggest that children with viral or Campylobacter diarrhea were taken to the hospital earlier than those infected with EPEC. One child infected with STEC O26 developed “complete” HUS. The microbiological results highlight the importance of zoonotic bacteria such as atypical EPEC, Campylobacter, STEC, and Salmonella as pathogens associated with acute diarrhea in these children. The findings also reinforce our previous communications about the regional importance of non-O157 STEC strains in severe infant food-borne diseases.

Prevalence of Shigella, Salmonella and Campylobacter species and their susceptibility patters among under five children with diarrhea in Hawassa town, south Ethiopia

Background

Diarrhea is the leading cause of morbidity and mortality in under-five children in developing countries including Ethiopia. Therefore, up-to-date data on etiologic agent and susceptibility pattern are important for the management of bacterial diarrhea in under-five children, which was the main objective of this study.

Method

A cross-sectional study was conducted at Hawassa Adare Hospital and Millennium Health Center from June 6 to October 28, 2011. A total of 158 under-five children with diarrhea were selected using convenient sampling technique. Demographic and clinical data were collected using questionnaire. Fecal samples were collected and processed for bacterial isolation, and antimicrobial susceptibility testing following standard bacteriological techniques.

Result

A total of 158 fecal samples were collected from 81(51.3%) males and 77(48.7%) females of under-five children with diarrhea. Of the 158 fecal samples, 35(22.2%) bacterial pathogens were isolated. The isolated bacteria were Campylobacter species, 20 (12.7%), Shigella species, 11 (7.0%), and Salmonella species, 4 (2.5%). The majority of the isolates were sensitive to Chloramphenicol, Ciprofloxacin, Nalidixic acid and Cotrimoxazol and high rate of drug resistance was observed against Erythromycin and Amoxicillin.

Conclusions

The finding of this study indicates that Campylobacter species were the predominant etiologies and the presence of bacterial isolates resistant to the commonly prescribed drugs for treating diarrhea in children. Therefore, periodic monitoring of etiologic agent with their drug resistant pattern is essential in the management of diarrhea in children.

Diarrhoea prevalence in children under five years of age in rural Burundi: an assessment of social and behavioural factors at the household level

BACKGROUND

Diarrhoea is the second leading cause of child mortality worldwide. Low- and middle-income countries are particularly burdened with this both preventable and treatable condition. Targeted interventions include the provision of safe water, the use of sanitation facilities and hygiene education, but are implemented with varying local success.

OBJECTIVE

To determine the prevalence of and factors associated with diarrhoea in children under five years of age in rural Burundi.

DESIGN

A cross-sectional survey was conducted among 551 rural households in northwestern Burundi. Areas of inquiry included 1) socio-demographic information, 2) diarrhoea period prevalence and treatment, 3) behaviour and knowledge, 4) socio-economic indicators, 5) access to water and water chain as well as 6) sanitation and personal/children's hygiene.

RESULTS

A total of 903 children were enrolled. The overall diarrhoea prevalence was 32.6%. Forty-six per cent (n=255) of households collected drinking water from improved water sources and only 3% (n=17) had access to improved sanitation. We found a lower prevalence of diarrhoea in children whose primary caretakers received hygiene education (17.9%), boiled water prior to its utilisation (19.4%) and were aged 40 or older (17.9%). Diarrhoea was associated with factors such as the mother's age being less than 25 and the conviction that diarrhoea could not be prevented. No gender differences were detected regarding diarrhoea prevalence or the caretaker's decision to treat.

CONCLUSIONS

Diarrhoea prevalence can be reduced through hygiene education and point-of use household water treatment such as boiling. In order to maximise the impact on children's health in the given rural setting, future interventions must assure systematic and regular hygiene education at the household and community level.

Clinical study of acute childhood diarrhoea caused by bacterial enteropathogens

OBJECTIVE

There are not a large number of studies in India which can enlighten us regarding acute childhood diarrhoea and far lesser in number when it comes to its bacterial enteropathogenesis. The present study is specially targeted to determine the prevalence of various bacterial enteropathogens causing acute childhood diarrhoea and to find out their respective pattern of clinical features.

METHOD

All children under 12 years of age enrolled between 1st June, 2012 and 31st July 2012, in the Outpatient department, Inpatient department of pediatrics section and casualty of hospital, who presented with acute diarrhoea. Data collected by mean of study questionnaire. Stool sample were processed for bacteriological analysis. In 280 samples bacteria were isolated with the help of microscopy, culture and biochemical reactions. The isolates obtained were tested for antimicrobial sensitivity over Mueller Hinton agar by Kirby Bauer-disk diffusion method.

RESULTS

Out of 280 children frequency of diarrhoeagenic bacteria isolated from the samples showed that Escherichia coli was recorded as the predominant bacteria with 44.2% of prevalence followed by Shigella, Salmonella, Klebsiella and Campylobacter with 28.2%, 13.6%, 7.8% and 6.1% respectively. Patients falling in the age group of 1-3 years. were the major sufferers of diarrhoea due to all etiologies except Klebsiella which mainly had impact on the patients below six months. Majority of isolated bacterial agents were resistant to Co-trimoxazole and Shigella being highly resistant enteropathogen isolated. Salmonella spp. were least resistant isolates. None of the isolates were resistant to Cefotaxime, Cefuroxime and Azetronam.

CONCLUSION

RESULTS of study reveal that Escherichia coli is a predominant bacterial enteropathogen causing diarrhoea and Salmonella is a major contributor to the diarrhoea causing severe dehydration and to the clinical features like fever, vomiting and more than 10 times of frequency of stools. Shigella is among highly resistant isolates while Salmonella isolates had least resistance to majority of antibiotics.

Genetic characterization of Shigella spp. isolated from diarrhoeal and asymptomatic children

Phenotypic and genetic characteristics of Shigella spp. isolated from diarrhoeal and asymptomatic children aged up to 5 years were analysed in this study. In total, 91 and 17 isolates were identified from diarrhoeal (case) and asymptomatic (control) children, respectively. All the isolates were tested for antimicrobial resistance, the presence of integrons, plasmid-mediated quinolone resistance (PMQR), virulence-associated genes and Shigella pathogenicity island (SH-PAI). The majority of the Shigella spp. from cases (68.1%) and controls (82.3%) were found to be resistant to fluoroquinolones. Integron carriage was detected more in cases (76.9%) than in controls (35.5%). Atypical class 1 integron was detected exclusively in Shigella flexneri from cases but not from the controls. PMQR genes such as aac(6')-Ib-cr and qnrS1 were detected in 82.4 and 14.3% of the isolates from cases and in 53 and 17.6% in controls, respectively. Shigella isolates from cases as well as from controls were positive for the invasive plasmid antigen H-encoding gene ipaH. The other virulence genes such as virF, sat, setA, setB, sen and ial were detected in Shigella isolates in 80.2, 49.4, 27.4, 27.4, 80.2 and 79.1% of cases and in 64.7, 52.9, 17.6, 17.6, 64.7 and 64.7% of controls, respectively. The entire SH-PAI was detected in S. flexneri serotype 2a from cases and controls. In an isolate from a control child, the SH-PAI was truncated. Integrons, PMQR and virulence-encoding genes were detected more frequently in cases than in controls. In diarrhoea endemic areas, asymptomatic carriers may play a crucial role in the transmission of multidrug-resistant Shigella spp. with all the putative virulence genes.

Can Giardia lamblia infection lower the risk of acute diarrhea among preschool children?

There are inconsistent findings concerning the role of Giardia lamblia in pediatric diarrhea. A prospective cohort study of the incidence of acute diarrhea among Israeli Arab preschool children offered the opportunity to examine the association between G. lamblia infection (at baseline) and subsequent diarrhea. Following baseline screening by light microscopy for the presence of Giardia in their stools, a cohort was assembled of 142 children who were followed between October 2003 and August 2004 for the incidence of diarrhea. Surveillance was performed through maternal interviews. At baseline, 21 children tested Giardia-positive. During the prospective surveillance, acute diarrhea occurred less often among Giardia-positive children (9.5%) than among children who were not infected with Giardia (26.5%). G. lamblia infection was associated with lower risk of acute diarrhea; adjusted odds ratio of 0.18 (95% confidence interval 0.04-0.93) (p = 0.041). This prospective study provides additional evidence that Giardia may lower the risk of subsequent acute diarrhea among preschool children.

Enteric pathogens in stored drinking water and on caregiver's hands in Tanzanian households with and without reported cases of child diarrhea

BACKGROUND

Diarrhea is one of the leading causes of mortality in young children. Diarrheal pathogens are transmitted via the fecal-oral route, and for children the majority of this transmission is thought to occur within the home. However, very few studies have documented enteric pathogens within households of low-income countries.

METHODS AND FINDINGS

The presence of molecular markers for three enteric viruses (enterovirus, adenovirus, and rotavirus), seven Escherichia coli virulence genes (ECVG), and human-specific Bacteroidales was assessed in hand rinses and household stored drinking water in Bagamoyo, Tanzania. Using a matched case-control study design, we examined the relationship between contamination of hands and water with these markers and child diarrhea. We found that the presence of ECVG in household stored water was associated with a significant decrease in the odds of a child within the home having diarrhea (OR = 0.51; 95% confidence interval 0.27-0.93). We also evaluated water management and hygiene behaviors. Recent hand contact with water or food was positively associated with detection of enteric pathogen markers on hands, as was relatively lower volumes of water reportedly used for daily hand washing. Enteropathogen markers in stored drinking water were more likely found among households in which the markers were also detected on hands, as well as in households with unimproved water supply and sanitation infrastructure.

CONCLUSIONS

The prevalence of enteric pathogen genes and the human-specific Bacteroidales fecal marker in stored water and on hands suggests extensive environmental contamination within homes both with and without reported child diarrhea. Better stored water quality among households with diarrhea indicates caregivers with sick children may be more likely to ensure safe drinking water in the home. Interventions to increase the quantity of water available for hand washing, and to improve food hygiene, may reduce exposure to enteric pathogens in the domestic environment.

Antimicrobial resistance in human and animal pathogens in Zambia, Democratic Republic of Congo, Mozambique and Tanzania: an urgent need of a sustainable surveillance system

A review of the published and unpublished literature on bacterial resistance in human and animals was performed. Sixty-eight articles/reports from the Democratic Republic of Congo (DRC), Mozambique, Tanzania and Zambia were reviewed. The majority of these articles were from Tanzania. There is an increasing trend in the incidence of antibiotic resistance; of major concern is the increase in multidrug- resistant Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Vibrio cholera, non-typhoid Salmonella and other pathogens responsible for nosocomial infections. The increase in methicillin- resistant Staphylococcus aureus and extended-spectrum beta-lactamase (ESBL) producers in the countries under review confirms the spread of these clones worldwide. Clinical microbiology services in these countries need to be strengthened in order to allow a coordinated surveillance for antimicrobial resistance and provide data for local treatment guidelines and for national policies to control antimicrobial resistance. While the present study does not provide conclusive evidence to associate the increasing trend in antibiotic resistance in humans with the use of antibiotics in animals, either as feed additives or veterinary prescription, we strongly recommend a one-health approach of systematic surveillance across the public and animal health sectors, as well as the adherence to the FAO (Food and Agriculture Organization)-OIE (World Organization of animal Health) –WHO(World Health Organization) recommendations for non-human antimicrobial usage.

Risk factors for sporadic infection with Salmonella Infantis: a matched case-control study

This matched case-control study investigated the risk factors for sporadic Salmonella Infantis infection in 263 affected children and 263 age-, gender- and neighbourhood-matched controls. Information about exposure to potential risk factors was obtained via telephone interview and evaluated by conditional logistic regression analysis. Age groups ≤ 1 year (n=77) and >1 year (n = 186) were analysed separately. Of those aged ≤ 1 year, breastfeeding was a significant protective factor against infection [matched odds ratio (mOR) 0.24, 95% confidence interval (CI) 0.10-0.59, P < 0.01]. In the older group, consumption of eggs (mOR 1.87, 95% CI 1.00-3.49, P = 0.05) was a significant risk factor and thawing chicken in water (mOR 2.55, 95% CI 0.94-6.91, P = 0.07) was borderline risk factor, while consumption of carrots (mOR 0.46, 95% CI 0.26-0.83, P < 0.01), drinking tap water (mOR 0.44, 95% CI 0.22-0.85, P = 0.02), religious lifestyle (mOR 0.40, 95% CI 0.21-0.74, P < 0.01) and having a high number of children in the household (mOR 0.72, 95% CI 0.58-0.88, P < 0.01) were significant protective factors. Consumers should avoid eating undercooked eggs and food handlers should be educated regarding proper handling and cooking of eggs. Breastfeeding should be strongly encouraged by public health authorities. The public must be educated on stringent hygiene practices, especially proper cooking of eggs to reduce infection rates.

The Global Enteric Multicenter Study (GEMS): impetus, rationale, and genesis

Diarrheal disease remains one of the top 2 causes of young child mortality in the developing world. Whereas improvements in water/sanitation infrastructure and hygiene can diminish transmission of enteric pathogens, vaccines can also hasten the decline of diarrheal disease morbidity and mortality. From 1980 through approximately 2004, various case/control and small cohort studies were undertaken to address the etiology of pediatric diarrhea in developing countries. Many studies had methodological limitations and came to divergent conclusions, making it difficult to prioritize the relative importance of different pathogens. Consequently, in the first years of the millennium there was no consensus on what diarrheal disease vaccines should be developed or implemented; however, there was consensus on the need for a well-designed study to obtain information on the etiology and burden of more severe forms of diarrheal disease to guide global investment and implementation decisions. Accordingly, the Global Enteric Multicenter Study (GEMS) was designed to overcome drawbacks of earlier studies and determine the etiology and population-based burden of pediatric diarrheal disease. GEMS, which includes one of the largest case/control studies of an infectious disease syndrome ever undertaken (target approximately 12 600 analyzable cases and 12 600 controls), was rolled out in 4 sites in sub-Saharan Africa (Gambia, Kenya, Mali, Mozambique) and 3 in South Asia (Bangladesh, India, Pakistan), with each site linked to a population under demographic surveillance (total approximately 467 000 child years of observation among children <5 years of age). GEMS data will guide investment and help prioritize strategies to mitigate the morbidity and mortality of pediatric diarrheal disease.

Statistical methods in the Global Enteric Multicenter Study (GEMS)

The Global Enteric Multicenter Study (GEMS) is an investigation of the burden (number of cases and incidence) of moderate-to-severe diarrhea (MSD) in children <60 months of age at 7 sites in sub-Saharan Africa and South Asia. The population attributable fraction for a putative pathogen, either unadjusted or adjusted for other pathogens, is estimated using the proportion of MSD cases from whom the pathogen was isolated and the odds ratio for MSD and the pathogen from conditional logistic regression modeling. The adjusted attributable fraction, proportion of MSD cases taken to a sentinel health center (SHC), number of cases presenting to an SHC, and the site's population are used to estimate the annual number of MSD cases and MSD incidence rate attributable to a pathogen or group of pathogens. Associations with death and nutritional outcomes, ascertained at follow-up visits to case and control households, are evaluated both in MSD cases and in the population.

Modifiable diarrhoea risk factors in Egyptian children aged <5 years

By conducting a case-control study in two university hospitals, we explored the association between modifiable risk behaviours and diarrhoea. Children aged <5 years attending outpatient clinics for diarrhoea were matched by age and sex with controls. Data were collected on family demographics, socioeconomic indicators, and risk behaviour practices. Two rectal swabs and a stool specimen were collected from cases and controls. Samples were cultured for bacterial pathogens using standard techniques and tested by ELISA to detect rotavirus andCryptosporidiumspp. Four hundred cases and controls were enrolled between 2007 and 2009. The strongest independent risk factors for diarrhoea were: presence of another household member with diarrhoea [matched odds ratio (mOR) 4·9, 95% CI 2·8–8·4] in the week preceding the survey, introduction to a new kind of food (mOR 3, 95% CI 1·7–5·4), and the child being cared for outside home (mOR 2·6, 95% CI 1·3–5·2). While these risk factors are not identifiable, in some age groups more easily modifiable risk factors were identified including: having no soap for handwashing (mOR 6·3, 95% CI 1·2–33·9) for children aged 7–12 months, and pacifier use (mOR 1·9, 95% CI 1·0–3·5) in children aged 0–6 months. In total, the findings of this study suggest that community-based interventions to improve practices related to sanitation and hygiene, handwashing and food could be utilized to reduce the burden of diarrhoea in Egyptian children aged <5 years.

Hands and water as vectors of diarrheal pathogens in Bagamoyo, Tanzania

Diarrheal disease is a leading cause of under-five childhood mortality worldwide, with at least half of these deaths occurring in sub-Saharan Africa. Transmission of diarrheal pathogens occurs through several exposure routes including drinking water and hands, but the relative importance of each route is not well understood. Using molecular methods, this study examines the relative importance of different exposure routes by measuring enteric bacteria (pathogenic Escherichia coli) and viruses (rotavirus, enterovirus, adenovirus) in hand rinses, stored water, and source waters in Bagamoyo, Tanzania. Viruses were most frequently found on hands, suggesting that hands are important vectors for viral illness. The occurrence of E. coli virulence genes (ECVG) was equivalent across all sample types, indicating that both water and hands are important for bacterial pathogen transmission. Fecal indicator bacteria and turbidity were good predictors of ECVG, whereas turbidity and human-specific Bacteroidales were good predictors of viruses. ECVG were more likely found in unimproved water sources, but both ECVG and viral genes were detected in improved water sources. ECVG were more likely found in stored water of households with unimproved sanitation facilities. The results provide insights into the distribution of pathogens in Tanzanian households and offer evidence that hand-washing and improved water management practices could alleviate viral and bacterial diarrhea.

A systematic review and meta-analysis of the association between Giardia lamblia and endemic pediatric diarrhea in developing countries

We performed a systematic literature review and meta-analysis examining the association between diarrhea in young children in nonindustrialized settings and Giardia lamblia infection. Eligible were case/control and longitudinal studies that defined the outcome as acute or persistent (>14 days) diarrhea, adjusted for confounders and lasting for at least 1 year. Data on G. lamblia detection (mainly in stools) from diarrhea patients and controls without diarrhea were abstracted. Random effects model meta-analysis obtained pooled odds ratios (ORs) and 95% confidence intervals (CIs). Twelve nonindustrialized-setting acute pediatric diarrhea studies met the meta-analysis inclusion criteria. Random-effects model meta-analysis of combined results (9774 acute diarrhea cases and 8766 controls) yielded a pooled OR of 0.60 (95% CI, .38-.94; P = .03), indicating that G. lamblia was not associated with acute diarrhea. However, limited data suggest that initial Giardia infections in early infancy may be positively associated with diarrhea. Meta-analysis of 5 persistent diarrhea studies showed a pooled OR of 3.18 (95% CI, 1.50-6.76; P < .001), positively linking Giardia with that syndrome. The well-powered Global Enteric Multicenter Study (GEMS) is prospectively addressing the association between G. lamblia infection and diarrhea in children in developing countries.

Escherichia coli expressing EAST1 toxin did not cause an increase of cAMP or cGMP levels in cells, and no diarrhea in 5-day old gnotobiotic pigs

Background

Enterotoxigenic Escherichia coli (ETEC) strains are the leading bacterial cause of diarrhea to humans and farm animals. These ETEC strains produce heat-labile toxin (LT) and/or heat-stable toxins that include type I (STa), type II (STb), and enteroaggregative heat-stable toxin 1 (EAST1). LT, STa, and STb (in pigs) are proven the virulence determinants in ETEC diarrhea. However, significance of EAST1 in ETEC-associated diarrheal has not been determined, even though EAST1 is highly prevalent among ETEC strains.

Methodology/Principal Findings

In this study, we constructed E. coli strains to express EAST1 toxin as the only toxin and studied them in cell lines and five-day old gnotobiotic piglets to determine significance of EAST1 toxin. Data from in vitro studies indicated that EAST1 did not stimulate an increase of intracellular cyclic AMP or GMP levels in T-84 cells or porcine cell line IPEC-J2, nor did it enhance LT or STa toxin of ETEC strains in stimulation of cAMP or cGMP in T-84 cells. In addition, 5-day old gnotobiotic pigs challenged with E. coli strains expressing EAST1 as the only toxin did not developed diarrhea or signs of clinical disease during 72 h post-inoculation.

Conclusion/Significance

Results from this study indicated that EAST1 alone is not sufficient to cause diarrhea in five-day old gnotobiotic pigs, and suggest that EAST1 likely is not a virulence determinant in ETEC-associated diarrhea.

Enteroaggregative Escherichia coli pathotype: a genetically heterogeneous emerging foodborne enteropathogen

Until now, a common feature that defines the enteroaggregative Escherichia coli (EAEC) strains is the ability to produce a 'stacked-brick' appearance on epithelial cells, but it does not distinguish between pathogenic and nonpathogenic strains. Numerous adhesins, toxins, and proteins associated with virulence have been described, as well as multiple factors contributing to EAEC-induced inflammation. None of these factors are found in all EAEC isolates, and no single factor has ever been implicated in EAEC virulence. The European outbreak of Shiga-toxin-producing EAEC raises its pathogenic potential and interest on finding the true pathogenic factors that may define this pathotype. EAEC were first associated with persistent diarrhea in infants from developing countries, since then they have increasingly been linked as a cause of acute and persistent diarrhea in young infants and children in developing and industrialized countries, individuals infected with human immunodeficiency virus, as a cause of acute diarrhea in travelers from industrialized regions, and with foodborne outbreaks. A major effect of EAEC infection is on the malnourished children in developing countries. Here, we will discuss the EAEC public health relevance and their complexity because of the strain heterogeneity regarding their pathogenesis, identification, diagnosis, lineage, epidemiology, and clinical manifestations.

Attaching and effacing Escherichia coli and Shiga toxin-producing E. coli in children with acute diarrhoea and controls in Teresina/PI, Brazil

This 3.5-year prospective study was conducted to ascertain the level of attaching and effacing Escherichia coli (AEEC) associated diarrhoea in children from Teresina, a northeastern state of Brazil. Passed faecal specimens from 400 patients (250 with and 150 without diarrhoea) up to 60 months of age attending from 2004 to 2007 at two public hospitals were investigated. Conventional microbiology methods and PCR were employed. Escherichia coli was isolated from 390 children, 240 of them with diarrhoea. A total of 117 AEEC strains were cultivated from specimens from 63 children, 37 with and 26 without diarrhoea. No association between AEEC and diarrhoea was observed. Atypical enteropathogenic E. coli (a-EPEC) (79.4%) was more commonly found than typical EPEC (t-EPEC). Association between EPEC and EPEC subtypes and diarrhoea was not detected. Mixed infection by t-EPEC and a-EPEC and infection by Shiga toxin-producing E. coli (STEC) were rare. Enteropathogenic E. coli was more common in males and in children aged less than 12 months. Correlation between serotyping and PCR results was 0.19. High resistance rates of AEEC to ampicillin, cephalotin, and trimethoprim-sulfamethoxazole were found. In conclusion, EPEC is very common in children with diarrhoea and controls in the population we studied, with a-EPEC predominating. This diarrhoeagenic E. coli (DEC) pathotype is more common in infant males and is resistant to drugs frequently used in clinical practice.

Protection against diarrhea associated with Giardia intestinalis Is lost with multi-nutrient supplementation: a study in Tanzanian children

BACKGROUND

Asymptomatic carriage of Giardia intestinalis is highly prevalent among children in developing countries, and evidence regarding its role as a diarrhea-causing agent in these settings is controversial. Impaired linear growth and cognition have been associated with giardiasis, presumably mediated by malabsorption of nutrients. In a prospective cohort study, we aim to compare diarrhea rates in pre-school children with and without Giardia infection. Because the study was conducted in the context of an intervention trial assessing the effects of multi-nutrients on morbidity, we also assessed how supplementation influenced the relationship between Giardia and diarrhoea rates, and to what extent Giardia modifies the intervention effect on nutritional status.

METHODS AND FINDINGS

Data were collected in the context of a randomized placebo-controlled efficacy trial with 2×2 factorial design assessing the effects of zinc and/or multi-micronutrients on morbidity (n=612; height-for-age z-score <-1.5 SD). Outcomes measures were episodes of diarrhea (any reported, or with ≥3 stools in the last 24 h) and fever without localizing signs, as detected with health-facility based surveillance. Giardia was detected in stool by enzyme-linked immunosorbent assay. Among children who did not receive multi-nutrients, asymptomatic Giardia infection at baseline was associated with a substantial reduction in the rate of diarrhea (HR 0.32; 0.15-0.66) and fever without localizing signs (HR 0.56; 0.36-0.87), whereas no such effect was observed among children who received multi-nutrients (p-values for interaction 0.03 for both outcomes). This interaction was independent of age, HAZ-scores and distance to the research dispensary. There was no evidence that Giardia modified the intervention effect on nutritional status.

CONCLUSION

Although causality of the Giardia-associated reduction in morbidity cannot be established, multi-nutrient supplementation results in a loss of this protection and thus seems to influence the proliferation or virulence of Giardia or associated intestinal pathogens.

Protection against diarrhea associated with Giardia intestinalis Is lost with multi-nutrient supplementation: a study in Tanzanian children

Background

Asymptomatic carriage of Giardia intestinalis is highly prevalent among children in developing countries, and evidence regarding its role as a diarrhea-causing agent in these settings is controversial. Impaired linear growth and cognition have been associated with giardiasis, presumably mediated by malabsorption of nutrients. In a prospective cohort study, we aim to compare diarrhea rates in pre-school children with and without Giardia infection. Because the study was conducted in the context of an intervention trial assessing the effects of multi-nutrients on morbidity, we also assessed how supplementation influenced the relationship between Giardia and diarrhoea rates, and to what extent Giardia modifies the intervention effect on nutritional status.

Methods and Findings

Data were collected in the context of a randomized placebo-controlled efficacy trial with 2×2 factorial design assessing the effects of zinc and/or multi-micronutrients on morbidity (n = 612; height-for-age z-score <−1.5 SD). Outcomes measures were episodes of diarrhea (any reported, or with ≥3 stools in the last 24 h) and fever without localizing signs, as detected with health-facility based surveillance. Giardia was detected in stool by enzyme-linked immunosorbent assay. Among children who did not receive multi-nutrients, asymptomatic Giardia infection at baseline was associated with a substantial reduction in the rate of diarrhea (HR 0.32; 0.15–0.66) and fever without localizing signs (HR 0.56; 0.36–0.87), whereas no such effect was observed among children who received multi-nutrients (p-values for interaction 0.03 for both outcomes). This interaction was independent of age, HAZ-scores and distance to the research dispensary. There was no evidence that Giardia modified the intervention effect on nutritional status.

Conclusion

Although causality of the Giardia-associated reduction in morbidity cannot be established, multi-nutrient supplementation results in a loss of this protection and thus seems to influence the proliferation or virulence of Giardia or associated intestinal pathogens.

Giardia intestinalis is a well-known cause of diarrhea in industrialized countries. In children in developing countries, asymptomatic infections are common and their role as cause of diarrhea has been questioned. In a cohort of rural Tanzanian pre-school children, we assessed the association between the presence of Giardia at baseline and subsequent diarrhea risk. The study was conducted in the context of a randomised trial assessing the effect of supplementation with zinc and other micro-nutrients on malaria, and half of the children daily received a multi-nutrient supplement. Surprisingly, we found that the presence of Giardia at baseline was associated with a substantial reduction in diarrhea risk. Multivariate statistical analysis showed that this protection could not be explained by differences in age or walking distance to the dispensary between children with and without Giardia. Because we cannot exclude that children differed in other (unmeasured) characteristics, we cannot draw firm conclusions about the causality of the observed association, but our findings support the view that the parasite is not an important cause of diarrhea in highly endemic settings. Striking was that the Giardia-associated protection was lost when children received multi-nutrients. Our data do not provide information about the mechanisms involved, but suggest that multi-nutrients may influence the compositionor pathogenicity of intestinal biota.

Relationship of the presence of a household improved latrine with diarrhea and under-five child mortality in Indonesia

We characterized the relationship of the presence of an improved latrine with diarrhea and under-five child mortality in Indonesia. The proportion of rural and urban families, respectively, without an improved latrine was 52.1% and 16.2%, with a child with a history of diarrhea in the last 7 days was 8.2% and 9.7%, and with a history of under-five child mortality was 11.1% and 8.5%. Among rural and urban families, respectively, lack of an improved latrine was associated with a child history of diarrhea in the last 7 days (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.18-1.29, P < 0.0001; OR = 1.20, 95% CI = 1.13-1.27, P < 0.0001) and under-five child mortality (OR = 1.29, 95% CI = 1.25-1.31, P < 0.0001; OR = 1.22, 95% CI = 1.12-1.32, P < 0.0001) in separate multivariable logistic regression models adjusting for covariates. The lack of a household improved latrine is associated with diarrhea and under-five child mortality in Indonesia.

Pediatric diarrhea in southern Ghana: etiology and association with intestinal inflammation and malnutrition

Diarrhea is a major public health problem that affects the development of children. Anthropometric data were collected from 274 children with (N = 170) and without (N = 104) diarrhea. Stool specimens were analyzed by conventional culture, polymerase chain reaction for enteroaggregative Escherichia coli (EAEC), Shigella, Cryptosporidium, Entamoeba, and Giardia species, and by enzyme-linked immunosorbent assay for fecal lactoferrin levels. About 50% of the study population was mildly to severely malnourished. Fecal lactoferrin levels were higher in children with diarrhea (P = 0.019). Children who had EAEC infection, with or without diarrhea, had high mean lactoferrin levels regardless of nutritional status. The EAEC and Cryptosporidium were associated with diarrhea (P = 0.048 and 0.011, respectively), and malnourished children who had diarrhea were often co-infected with both Cryptosporidium and EAEC. In conclusion, the use of DNA-biomarkers revealed that EAEC and Cryptosporidium were common intestinal pathogens in Accra, and that elevated lactoferrin was associated with diarrhea in this group of children.

A systematic review and meta-analysis of the association between self-reported diarrheal disease and distance from home to water source

The aim of this study was to identify whether there was a relationship between the distance that people have to carry water home and ill health. We conducted a systematic review for papers that reported on the association between diarrheal risk and distance. Six papers were identified for inclusion in the meta-analysis. These were all observational studies, and only two reported effect sizes that adjusted for possible confounding. Multiple different types of water sources supplied the study communities. The combined odds ratio (OR) showed a significant increase in illness risk in people living farther away from their water source (OR = 1.45; 95% confidence interval [CI] = 1.04-1.68). There is a need for better designed studies to further elucidate the health impacts on having to carry water home.

Assessment of latrine use and quality and association with risk of trachoma in rural Tanzania

The existing evidence regarding latrines and trachoma is inconclusive. Using more precise sanitation measures we examine the association between use and quality of latrines and risk of trachoma. We conducted a case-control study of 678 households (95 cases, 583 controls) in eight villages in Kongwa District, Tanzania. Case households were defined as having a sentinel child with clinical signs of trachoma. A latrine quality score was calculated based on seven indicators and case and control households were compared with respect to use and quality of latrines. Logistic regression analyses controlled for potential confounders. Latrine use was significantly greater in control households than in case households (90.4 vs. 76.8%, P=0.03). The protective effect of latrine use persisted even after controlling for household characteristics significant at P <0.20 (adjusted OR=0.56 [95% CI: 0.32-0.98]). Contrary to expectation, we did not find an inverse association between increasing latrine quality and decreasing odds of trachoma. Although latrine use in the communities was high, latrines, regardless of quality, were significantly associated with decreased risk of trachoma. These findings underscore the importance of achieving 100% latrine use in communities.

Rapid Diagnosis of Intestinal Parasitic Protozoa, with a Focus on Entamoeba histolytica

Entamoeba histolytica is an invasive intestinal pathogenic parasitic protozoan that causes amebiasis. It must be distinguished from Entamoeba dispar and E. moshkovskii, nonpathogenic commensal parasites of the human gut lumen that are morphologically identical to E. histolytica. Detection of specific E. histolytica antigens in stools is a fast, sensitive technique that should be considered as the method of choice. Stool real-time PCR is a highly sensitive and specific technique but its high cost make it unsuitable for use in endemic areas where there are economic constraints. Serology is an important component of the diagnosis of intestinal and especially extraintestinal amebiasis as it is a sensitive test that complements the detection of the parasite antigens or DNA. Circulating Gal/GalNac lectin antigens can be detected in the serum of patients with untreated amoebic liver abscess. On the horizon are multiplex real-time PCR assays which permit the identification of multiple enteropathogens with high sensitivity and specificity.

Prospective case-control study of the association between common enteric protozoal parasites and diarrhea in Bangladesh

BACKGROUND

The parasitic causes of diarrhea have historically been identified by use of microscopy; however, the use of this technique does not allow one to distinguish between subspecies or genotypes of parasites. Our objective was to determine, by use of modern diagnostic methods, the proportion of diarrhea cases in Bangladesh attributable to Cryptosporidium hominis, Cryptosporidium parvum, Entamoeba histolytica, and Giardia lamblia assemblages A and B.

METHODS

A prospective case-control study was performed involving 3646 case patients (both children and adults) who presented with diarrhea to the Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh, and 2575 control subjects with asymptomatic infection. Parasitic infection was detected by use of a stool parasite antigen test, and the parasite load and the species and/or genotypes were determined by use of polymerase chain reaction (PCR).

RESULTS

Cryptosporidium species and E. histolytica were more prevalent in patients with acute diarrhea than in healthy control subjects, for all ages (2.1% vs. 1.4%; P = .039) and, specifically, for those 0-12 months of age (2.2% vs. 0.4%; P = .009). G. lamblia assemblage A was also more prevalent in case patients with diarrhea than in healthy control subjects (20% vs. 5%; P = .001). For case patients with diarrhea, the parasite load in feces, as measured by quantitative real-time PCR cycle threshold, was not higher that that for control subjects with asymptomatic infection. Case patients with diarrhea and cryptosporidiosis were less likely to have abdominal pain, compared with control subjects (15% vs. 37%; P = .001); case patients with amebiasis more likely to have visible blood in stool, compared with control subjects (8% vs. 1.6%; P = .001); and case patients with giardiasis more likely to be dehydrated, compared with control subjects (81% vs. 71%; P = .001).

CONCLUSION

E. histolytica, C. hominis, C. parvum, and G. lamblia assemblage A infections are important causes of diarrheal illness in Bangladesh.

Pathogenic microorganisms associated with childhood diarrhea in low-and-middle income countries: case study of Yaoundé - Cameroon

Notwithstanding significant advancement in the understanding of pathogenesis and management, diarrheal illnesses remain one of the principal causes of global childhood mortality and morbidity. Infections account for most illnesses, with pathogens employing ingenious mechanisms to establish disease. In 2002, an interdisciplinary program "Populations et al. Espaces à Risques SANitaires" (PERSAN) was set up under the patronage of the Development Research Institute (IRD). Focused on health in Cameroon's urban environment, the program mainly sought to identify diarrhea risk factors in Yaoundé. So for, a cross-sectional epidemiological study in children aged 6-59 months was carried out using a standardized protocol. The survey was initiated in 2002 and conducted during April to June in the year 2005. 3,034 stool samples were collected from children in twenty neighbourhoods in Yaoundé and examined at the Epidemiology and Public Health Laboratory of the Cameroon Pasteur Institute. About 60% of the patients were aged less than two years and 52% were male. Among the 437 patients with the diarrheal disease, 260 were found to be of infectious etiology, i.e. micro organism was detected in 59.5% of the cases. Out of which, 10 (03.8%), 96 (36.9%), and 154 (59.2%) were respectively caused by pathogenic viruses, pathogenic bacteria and pathogenic parasites. Higher prevalence was found in overcrowded and under supply spontaneous settlement (78.4%) than in less crowded and formal residential settlement (21.5%). Etiologic data on diarrheal diseases and their spatial distribution are important tools for public health management and control strategic planning.