Systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries

Spatiotemporal analysis of diarrhea-related hospitalizations of children in Brazil's Midwest region from 2011 to 2020

OBJECTIVE

To examine spatiotemporal variability and identify clustering patterns of hospitalization rates for diarrhea in children younger than five years in Mato Grosso, Brazil, from 2011 to 2020.

METHODS

An ecological study was conducted using hospitalization records associated with diarrhea from the Brazilian Hospital Information System/Unified Health System. The relative risk of hospitalization for diarrhea in each municipality was calculated using SaTScan software considering a statistical significance level of 5% and 999 Monte Carlo replications.

RESULTS

A total of 13,315 diarrhea-associated hospitalizations for 5-year-old children were recorded. From 2011 to 2020, the annual rates for hospitalizations related to diarrhea decreased from 8.50 to 3.45/1,000 live births among children younger than one year and from 4.99 to 1.57 for children aged 1-4 years. Clusters of municipalities with high relative risk for hospitalizations due to diarrhea, statistically significant, predominated in the North, Northeast, and Southwest health administrative macro-regions of Mato Grosso for both age groups until 2016. From 2016 to 2020, clusters of the lowest relative risk were identified in the North and Center South health administrative macro-regions for children younger than five years.

CONCLUSION

Results showed that hospitalization rates for diarrhea in children younger than five years reduced with the presence of low-risk clusters in Mato Grosso in the final years of the study. Public health surveillance should incorporate spatial analysis to investigate the diarrhea-related morbidity.

The role of rapid syndromic diagnostic testing of gastrointestinal pathogens as a clinical decision support tool in a pediatric emergency department

PURPOSE

This study aimed to investigate the role of rapid syndromic diagnostic testing of gastrointestinal pathogens as a clinical decision support tool in a pediatric emergency department (ED) by comparing clinical decision and patient outcome parameters pre- and post-implementation.

METHODS

This was a big data analytical study of children < 18 years old without any underlying diseases, that visited the ED with acute moderate to severe diarrhea during a 34-month period from 2018 to 2022 using Seoul St. Mary's hospital's healthcare corporate data warehouse to retrieve demographic, clinical, and laboratory parameters. Outcome measures pre- and post-implementation of a rapid syndromic multiplex gastrointestinal panel (GI panel) were compared.

RESULTS

A total of 4,184 patients' data were included in the analyses. Broad spectrum antibiotics were prescribed at a significantly lower rate to patients presenting with acute infectious diarrhea at discharge from the ED (9.9% vs 15.8%, P < 0.001) as well as upon admission (52.2% vs 66.0%, P < 0.001) during the post-implementation period compared to the pre-implementation period. Although the duration of ED stay was found to be significantly longer (6.5 vs 5.5 h, P < 0.0001), the rate of ED revisit due to persistent or aggravated symptoms was significantly lower (Δ in intercept, β = -0.027; SE = 0.013; P = 0.041), and the admission rate at follow up after being discharged from the ED shown to be significantly lower during the post-implementation period compared to the pre-implementation period (0.8% vs. 2.1%, P = 0.001, respectively). No significant difference in disease progression was observed (P = 1.000).

CONCLUSION

Using the GI panel in the ED was shown to decrease broad spectrum antibiotic prescribing practices and reduce revisits or admission at follow up by aiding clinical decisions and improving patient outcome.

Pharmacomicrobiomics and Drug-Infection Interactions: The Impact of Commensal, Symbiotic and Pathogenic Microorganisms on a Host Response to Drug Therapy

Microorganisms have a close relationship with humans, whether it is commensal, symbiotic, or pathogenic. Recently, it has been documented that microorganisms may influence the response to drug therapy. Pharmacomicrobiomics is an emerging field that focuses on the study of how variations in the microbiome affect the disposition, action, and toxicity of drugs. Two additional sciences have been added to complement pharmacomicrobiomics, namely toxicomicrobiomics, which explores how the microbiome influences drug metabolism and toxicity, and pharmacoecology, which refers to modifications in the microbiome as a result of drug administration. In this context, we introduce the concept of "drug-infection interaction" to describe the influence of pathogenic microorganisms on drug response. This review analyzes the current state of knowledge regarding the relevance of microorganisms in the host's response to drugs. It also highlights promising areas for future research and proposes the term "drug-infection interaction" as an extension of pharmacomicrobiomics.

Vaccine value profile for Shigella

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

A First in Human Clinical Trial Assessing the Safety and Immunogenicity of Two Intradermally Delivered Enterotoxigenic Escherichia coli CFA/I Fimbrial Tip Adhesin Antigens with and without Heat-Labile Enterotoxin with Mutation LT(R192G)

INTRODUCTION

Enterotoxigenic E. coli (ETEC) is a leading cause of diarrhea in travelers as well as for children living in low- to middle-income countries. ETEC adhere to intestinal epithelium via colonization factors (CFs). CFA/I, a common CF, is composed of a polymeric stalk and a tip-localized minor adhesive subunit, CfaE. Vaccine delivery by the transcutaneous immunization of dscCfaE was safe but was poorly immunogenic in a phase 1 trial when administered to volunteers with LTR(192G) and mLT. To potentially enhance the immunogenicity of CfaE while still delivering via a cutaneous route, we evaluated the safety and immunogenicity of two CfaE constructs administered intradermally (ID) with or without mLT.

METHODS

CfaE was evaluated as a donor strand-complemented construct (dscCfaE) and as a chimeric construct (Chimera) in which dscCfaE replaces the A1 domain of the cholera toxin A subunit and assembles non-covalently with the pentamer of heat-labile toxin B (LTB). Subjects received three ID vaccinations three weeks apart with either dscCfaE (1, 5, and 25 µg) or Chimera (2.6 and 12.9 µg) with and without 0.1 µg of mLT. Subjects were monitored for local and systemic adverse events. Immunogenicity was evaluated by serum and antibody-secreting cell (ASC) responses.

RESULTS

The vaccine was well-tolerated with predominantly mild and moderate local vaccine site reactions characterized by erythema, induration and post-inflammatory hyperpigmentation. High rates of serologic and ASC responses were seen across study groups with the most robust responses observed in subjects receiving 25 µg of dscCfaE with 0.1 mcg of LT(R192G).

CONCLUSION

Both ETEC adhesin vaccine prototypes were safe and immunogenic when co-administered with mLT by the ID route. The observed immune responses induced with the high dose of dscCfaE and mLT warrant further assessment in a controlled human infection model.

A comparison of the NIRUDAK models and WHO algorithm for dehydration assessment in older children and adults with acute diarrhoea: a prospective, observational study

BACKGROUND

Despite the importance of accurate and rapid assessment of hydration status in patients with acute diarrhoea, no validated tools exist to help clinicians assess dehydration severity in older children and adults. The aim of this study is to validate a clinical decision support tool (CDST) and a simplified score for dehydration severity in older children and adults with acute diarrhoea (both developed during the NIRUDAK study) and compare their accuracy and reliability with current WHO guidelines.

METHODS

A random sample of patients aged 5 years or older presenting with diarrhoea to the icddr,b Dhaka Hospital in Bangladesh between Jan 30 and Dec 13, 2022 were included in this prospective cohort study. Patients with fewer than three loose stools per day, more than 7 days of symptoms, previous enrolment in the study, or a diagnosis other than acute gastroenteritis were excluded. Patients were weighed on arrival and assessed separately by two nurses using both our novel clinical tools and WHO guidelines. Patients were weighed every 4 h to determine their percent weight change with rehydration, our criterion standard for dehydration. Accuracy for the diagnosis of dehydration category (none, some, or severe) was assessed using the ordinal c-index (ORC). Reliability was assessed by comparing the prediction of severe dehydration from each nurse's independent assessment using the intraclass correlation coefficient (ICC).

FINDINGS

1580 patients were included in our primary analysis, of whom 921 (58·3%) were female and 659 (41·7%) male. The ORC was 0·74 (95% CI 0·71-0·77) for the CDST, 0·75 (0·71-0·78) for the simplified score, and 0·64 (0·61-0·67) for the WHO guidelines. The ICC was 0·98 (95% CI 0·97-0·98) for the CDST, 0·94 (0·93-0·95) for the simplified score, and 0·56 (0·52-0·60) for the WHO guidelines.

INTERPRETATION

Use of our CDST or simplified score by clinicians could reduce undertreatment and overtreatment of older children and adults with acute diarrhoea, potentially reducing morbidity and mortality for this common disease.

FUNDING

US National Institutes of Health.

TRANSLATION

For the Bangla translation of the abstract see Supplementary Materials section.

Symptoms, Treatment, and Outcomes of COVID-19 Patients Coinfected with Clostridioides difficile: Single-Center Study from NE Romania during the COVID-19 Pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has brought new challenges across medical disciplines, particularly in infectious disease medicine. In Romania, the incidence of SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) infection increased dramatically since March 2020 until March 2022. Antibiotic administration for pulmonary superinfections in COVID-19 intensified and, consequently, increased rates of Clostridioides difficile infection (CDI) were hypothesized. We conducted a single-center, retrospective, observational study on patients from North-Eastern Romania to assess clinical characteristics and outcomes of COVID-19 and Clostridioides difficile (CD) coinfection, and to identify risk factors for CDI in COVID-19 patients. The study enrolled eighty-six CDI and COVID-19 coinfected patients admitted during March 2020-February 2021 (mean age 59.14 years, 53.49% men, 67.44% urban residents) and a group of eighty-six COVID-19 patients. On admission, symptoms were more severe in mono-infected patients, while coinfected patients associated a more intense acute inflammatory syndrome. The main risk factors for severe COVID-19 were smoking, diabetes mellitus, and antibiotic administration. Third generation cephalosporins (55%) and carbapenems (24%) were the main antibiotics used, and carbapenems were significantly associated with severe COVID-19 in patients coinfected with CD during hospitalization. Coinfection resulted in longer hospitalization and poorer outcomes. The extensive use of antibiotics in COVID-19, particularly carbapenems, contributed substantially to CD coinfection.

Effects of Ambient Temperature, Relative Humidity, and Precipitation on Diarrhea Incidence in Surabaya

BACKGROUND

Diarrhea remains a common infectious disease caused by various risk factors in developing countries. This study investigated the incidence rate and temporal associations between diarrhea and meteorological determinants in five regions of Surabaya, Indonesia.

METHOD

Monthly diarrhea records from local governmental health facilities in Surabaya and monthly means of weather variables, including average temperature, precipitation, and relative humidity from Meteorology, Climatology, and Geophysical Agency were collected from January 2018 to September 2020. The generalized additive model was employed to quantify the time lag association between diarrhea risk and extremely low (5th percentile) and high (95th percentile) monthly weather variations in the north, central, west, south, and east regions of Surabaya (lag of 0-2 months).

RESULT

The average incidence rate for diarrhea was 11.4 per 100,000 during the study period, with a higher incidence during rainy season (November to March) and in East Surabaya. This study showed that the weather condition with the lowest diarrhea risks varied with the region. The diarrhea risks were associated with extremely low and high temperatures, with the highest RR of 5.39 (95% CI 4.61, 6.17) in the east region, with 1 month of lag time following the extreme temperatures. Extremely low relative humidity increased the diarrhea risks in some regions of Surabaya, with the highest risk in the west region at lag 0 (RR = 2.13 (95% CI 1.79, 2.47)). Extremely high precipitation significantly affects the risk of diarrhea in the central region, at 0 months of lag time, with an RR of 3.05 (95% CI 2.09, 4.01).

CONCLUSION

This study identified a high incidence of diarrhea in the rainy season and in the deficient developed regions of Surabaya, providing evidence that weather magnifies the adverse effects of inadequate environmental sanitation. This study suggests the local environmental and health sectors codevelop a weather-based early warning system and improve local sanitation practices as prevention measures in response to increasing risks of infectious diseases.

Zinc agronomic biofortification of staple crops may be a cost-effective strategy to alleviate zinc deficiency in Ethiopia

BACKGROUND

Inadequate dietary zinc (Zn) supplies and Zn deficiency (ZnD) are prevalent in Ethiopia, where cereals are major dietary sources, yet low in bioavailable Zn. Zinc agronomic biofortification (ZAB) of staple crops through application of Zn fertilizers may contribute to alleviating ZnD. However, large-scale promotion and adoption of ZAB requires evidence of the feasibility and public health benefits. This paper aimed to quantify the potential cost-effectiveness of ZAB of staple crops for alleviating ZnD in Ethiopia.

METHODS

Current burden of ZnD among children in Ethiopia was quantified using a disability-adjusted life years (DALYs) framework. Evidence on baseline dietary Zn intake, cereal consumption, and fertilizer response ratio was compiled from existing literature and secondary data sources. Reduction in the burden of ZnD attributable to ZAB of three staple cereals (maize, teff, and wheat) via granular and foliar Zn fertilizer applications was calculated under optimistic and pessimistic scenarios. The associated costs for fertilizer, labor, and equipment were estimated in proportion to the cropping area and compared against DALYs saved and the national Gross Domestic Product capita-1.

RESULTS

An estimated 0.55 million DALYs are lost annually due to ZnD, mainly due to ZnD-related mortality (91%). The ZAB of staple cereals via granular Zn fertilizer could reduce the burden of ZnD by 29 and 38% under pessimistic and optimistic scenarios, respectively; the respective values for ZAB via foliar application were 32 and 40%. The ZAB of staple cereals via granular fertilizer costs US$502 and US$505 to avert each DALY lost under optimistic and pessimistic scenarios, respectively; the respective values for ZAB via foliar application were US$226 and US$ 496. Foliar Zn application in combination with existing pesticide use could reduce costs to US$260-353 for each DALY saved. Overall, ZAB of teff and wheat were found to be more cost-effective in addressing ZnD compared to maize, which is less responsive to Zn fertilizer.

CONCLUSION

ZAB of staple crops via granular or foliar applications could be a cost-effective strategy to address ZnD, which can be integrated with the existing fertilizer scheme and pesticide use to minimize the associated costs.

Cost-effectiveness of universal iron supplementation and iron-containing micronutrient powders for anemia among young children in rural Bangladesh: analysis of a randomized, placebo-controlled trial

BACKGROUND

Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC (Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh.

OBJECTIVES

We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh.

METHODS

We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results.

RESULTS

Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 [half of gross domestic product (GDP) per capita] per DALY averted. Scenario and sensitivity analyses supported the base case findings.

CONCLUSIONS

These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh.This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.

Prevalence and determinants of diarrhea among under-five children in five Southeast Asian countries: Evidence from the demographic health survey

PURPOSE

To describe the prevalence and the correlation between individual, environmental and household, health behavior, and source of information factors with diarrhea among under-five children in five Southeast Asian countries based on the National Health Survey.

DESIGN AND METHODS

Cross-sectional design conducted in five countries in Southeast Asia. Datasets from Demographic and Health Surveys and Multiple Indicator Cluster Surveys in five countries were analyzed.

RESULTS

A total of 12,447 children under 5 years of age from five countries in Southeast Asia (Indonesia 1807, Cambodia 2650, Myanmar 1717, the Philippines 3669, and Timor-Leste 2614) were included in this study. Binary logistic regression was performed to analyze the data. A total of 12,447 under-five children were included in the study. Overall, in five Southeast Asian countries, the prevalence of diarrhea is known from 8.39% in the Philippines to 18.21% in Indonesia. Several factors related to diarrhea are individual; environmental and household; health behavior such as stool disposal, breastfeeding mothers, and children's food history; and source of information factors.

CONCLUSION

The findings of this study indicate that diarrhea is a serious public health problem in the Southeast Asian region that must be addressed using preventive and curative approaches.

PRACTICE IMPLICATION

The results indicate the need for cross-collaboration among nurses, medical doctor, and sanitarian is needed to tackle the childhood diarrhea and minimize the severity based on those determinants.

Floods and diarrheal morbidity: Evidence on the relationship, effect modifiers, and attributable risk from Sichuan Province, China

Background

Although studies have provided the estimates of floods-diarrhoea associations, little is known about the lag effect, effect modification, and attributable risk. Based on Sichuan, China, an uneven socio-economic development province with plateau, basin, and mountain terrains spanning different climatic zones, we aimed to systematically examine the impacts of floods on diarrheal morbidity.

Methods

We retrieved information on daily diarrheal cases, floods, meteorological variables, and annual socio-economic characteristics for 21 cities in Sichuan from January 1, 2017 to December 31, 2019. We fitted time-series Poisson models to estimate the city-specific floods-diarrhoea relation over the lags of 0-14 days, and then pooled them using meta-analysis for cumulative and lag effects. We further employed meta-regression to explore potential effect modifiers and identify effect modification. We calculated the attributable diarrheal cases and fraction of attributable morbidity within the framework of the distributed lag model.

Results

Floods had a significant cumulative association with diarrhoea at the provincial level, but varied by regions and cities. The effects of the floods appeared on the second day after the floods and lasted for 5 days. Floods-diarrhoea relations were modified by three effect modifiers, with stronger flood effects on diarrhoea found in areas with higher air pressure, lower diurnal temperature range, or warmer temperature. Floods were responsible for advancing a fraction of diarrhoea, corresponding to 0.25% within the study period and 0.48% within the flood season.

Conclusions

The impacts imposed by floods were mainly distributed within the first week. The floods-diarrhoea relations varied by geographic and climatic conditions. The diarrheal burden attributable to floods is currently low in Sichuan, but this figure could increase with the exposure more intensive and the effect modifiers more detrimental in the future. Our findings are expected to provide evidence for the formulation of temporal- and spatial-specific strategies to reduce potential risks of flood-related diarrhoea.

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

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

Cost-effectiveness of Zinc Supplementation for Prevention of Childhood Diarrhoea in Tanzania

OBJECTIVE

To assess the cost-effectiveness of prophylactic zinc supplementation for preventing diarrhoea in young children in Tanzania.

DESIGN

Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3% discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions.

SETTING

Tanzania.

PARTICIPANTS

A hypothetical cohort of 10,000 children ages 6 weeks to 18 months.

RESULTS

The intervention costs of zinc supplementation were estimated as $109,800 (95% uncertainty interval: 61,716-171,507). Zinc supplementation was estimated to avert 2,200 (776-3,737) diarrhoeal episodes, 14,080 (4,692-25,839) sick days, 1,584 (522-2,927) outpatient visits, 561 (160-1,189) inpatient bed-days, 0.51 (0.15-1.03) deaths, and 19.3 (6.1-37.5) DALYs (discounted at 3% per year). Zinc supplementation reduced diarrhoea care costs by $12, 887 (4,089-25,058). The incremental cost per DALY averted was $4,950 (1,678-17,933). Incremental cost-effectiveness ratios (ICERs) estimated from a health system perspective were similar to the results from the societal perspective. ICERs were substantially lower (more favourable) when future outcomes were not discounted, but all ICERs were above contemporary thresholds for cost-effectiveness in this setting.

CONCLUSION

Prophylactic zinc reduced diarrhoea incidence and associated healthcare utilization; however it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.

Socioeconomic Burden of Bloodstream Infections Caused by Carbapenem-Resistant Enterobacteriaceae

Background

Although infection with carbapenem-resistant Enterobacteriaceae (CRE) has become an urgent public health threat worldwide, the socioeconomic burden of CRE bloodstream infection (BSI) remains to be clarified.

Methods

This retrospective study included all patients infected with Escherichia coli or Klebsiella pneumoniae who were hospitalized for BSI from 2013 to 2015. Socioeconomic burden, including direct and indirect economic burden, was compared in patients infected with carbapenem-sensitive Enterobacteriaceae (CSE) and CRE following 1:1 propensity score matching (PSM) to control for confounding variables.

Results

Data from 879 patients with Enterobacteriaceae BSI were evaluated, including 152 (17.3%) patients infected with CRE and 727 (82.7%) infected with CSE. PSM yielded 112 pairs of 224 patients. Median hospital length of stay did not differ significantly in the CRE and CSE groups (35 vs 29 days, P = 0.089), but in-hospital 28-day mortality rate was significantly higher in patients infected with CRE than with CSE (45.5% vs 32.1%, P = 0.040). Median direct economic burden was significantly greater in patients with CRE-BSI than with CSE-BSI during hospitalization ($24,940.1 vs 16,864.0, P = 0.017) but not during the period after infection ($10,403.4 vs 8498.0, P = 0.178). Drug expenditure accounted for the largest proportion of costs in both groups. The median disability-adjusted life year (DALY) was higher in CRE-BSI than in CSE-BSI patients, but the difference was not statistically significant (7.9 vs 6.7 years, P = 0.190). Median indirect economic burden did not differ significantly in these two groups ($3848.5 vs 1139.9, P = 0.304), although indirect economic burden increased significantly from 2013 to 2015 in patients with CRE-BSI.

Conclusion

Carbapenem resistance had a major impact on the clinical and socioeconomic burden of patients with Enterobacteriaceae BSI. The higher mortality rate in patients with CRE-BSI was associated with increased direct healthcare burden and indirect socioeconomic loss.

Assessing the performance of clinical diagnostic models for dehydration among patients with cholera and undernutrition in Bangladesh

OBJECTIVE

Accurately assessing dehydration severity is a critical step in reducing mortality from diarrhoea, but is complicated by cholera and undernutrition. This study seeks to assess the accuracy of two clinical diagnostic models for dehydration among patients over five years with cholera and undernutrition and compare their respective performance to the World Health Organization (WHO) algorithm.

METHODS

In this secondary analysis of data collected from the NIRUDAK study, accuracy of the full and simplified NIRUDAK models for predicting severe and any dehydration was measured using the area under the Receiver Operator Characteristic curve (AUC) among patients over five with/without cholera and with/without wasting. Bootstrap with 1000 iterations was used to compare the m-index for each NIRUDAK model to that of the WHO algorithm.

RESULTS

A total of 2,139 and 2,108 patients were included in the nutrition and cholera subgroups respectively with an overall median age of 35 years (IQR = 42) and 49.6% female. All subgroups had acceptable discrimination in diagnosing severe or any dehydration (AUC > 0.60); though the full NIRUDAK model performed best among patients without cholera, with an AUC of 0.82 (95%CI:0.79, 0.85) and among patients without wasting, with an AUC of 0.79 (95%CI:0.76, 0.81). Compared with the WHO's algorithm, both the full and simplified NIRUDAK models performed significantly better in terms of their m-index (p < 0.001) for all comparisons, except for the simplified NIRUDAK model in the wasting group.

CONCLUSIONS

Both the full and simplified NIRUDAK models performed less well in patients over five years with cholera and/or wasting; however, both performed better than the WHO algorithm.

High-throughput low-cost nl-qPCR for enteropathogen detection: A proof-of-concept among hospitalized patients in Bangladesh

Background

Diarrheal disease is a leading cause of morbidity and mortality globally, especially in low- and middle-income countries. High-throughput and low-cost approaches to identify etiologic agents are needed to guide public health mitigation. Nanoliter-qPCR (nl-qPCR) is an attractive alternative to more expensive methods yet is nascent in application and without a proof-of-concept among hospitalized patients.

Methods

A census-based study was conducted among diarrheal patients admitted at two government hospitals in rural Bangladesh during a diarrheal outbreak period. DNA was extracted from stool samples and assayed by nl-qPCR for common bacterial, protozoan, and helminth enteropathogens as the primary outcome.

Results

A total of 961 patients were enrolled; stool samples were collected from 827 patients. Enteropathogens were detected in 69% of patient samples; More than one enteropathogen was detected in 32%. Enteropathogens most commonly detected were enteroaggregative Escherichia coli (26.0%), Shiga toxin-producing E.coli (18.3%), enterotoxigenic E. coli (15.5% heat stable toxin positive, 2.2% heat labile toxin positive), Shigella spp. (14.8%), and Vibrio cholerae (9.0%). Geospatial analysis revealed that the median number of pathogens per patient and the proportion of cases presenting with severe dehydration were greatest amongst patients residing closest to the study hospitals.”

Conclusions

This study demonstrates a proof-of-concept for nl-qPCR as a high-throughput low-cost method for enteropathogen detection among hospitalized patients.

Introducing Rotavirus Vaccination in Nigeria: Economic Evaluation and Implications

BACKGROUND

As Nigeria prepares to introduce a rotavirus vaccine, the Gavi board has approved the extension of the transition period for the country until 2028. The current position of the country on Gavi's funding profile calls for a pragmatic step in planning and implementation so that sustainability at the fully self-financing phase will be feasible.

OBJECTIVE

This study aimed to inform the decisions of the country's health policymakers on the costs, benefits, and implications of the introduction of rotavirus vaccine.

METHODS

This study was an economic evaluation using a simulation-based Markov model. It compared four approaches: 'no vaccination' and vaccination with ROTARIX, ROTAVAC, or ROTASIIL. Ten cohorts from the year 2021 to 2030 were used in the analysis. Primary measures were the benefit-cost ratio (BCR) and the incremental cost-effectiveness ratio (ICER). Future costs and outcomes were discounted to 2019 values.

RESULTS

The adjusted vaccine cost of ROTARIX was the highest, followed by ROTAVAC and ROTASIIL, whereas the immunization delivery cost was in the reverse order. All the vaccines were very cost effective, with ROTARIX being the optimal choice for the 10-year period, having a BCR of 27 and an ICER of $US100 (95% confidence interval [CI] 71-130)/disability-adjusted life-year averted. Adopting ROTARIX was the optimal choice from 2021 to 2027, whereas ROTAVAC was optimal from 2028 to 2030. The net budget impact of the programme was $US76.9 million for the 10-year period. The opportunity cost of a late introduction was about $US8 million per annum from 2021 to 2028.

CONCLUSIONS

The rotavirus vaccine ROTARIX should be implemented in Nigeria at the earliest opportunity. A switch to ROTAVAC should be considered from the year 2028. Cost-minimization measures are imperative to ensure the sustainability of the programme after the transition out of Gavi support.

Derivation and Internal Validation of a Score to Predict Dehydration Severity in Patients over 5 Years with Acute Diarrhea

Diarrheal disease accounts for more than one million deaths annually in patients over 5 years of age. Although most patients can be managed with oral rehydration solution, patients with severe dehydration require resuscitation with intravenous fluids. Scoring systems to assess dehydration have been empirically derived and validated in children under 5 years, but none have been validated for patients over 5 years. In this study, a prospective cohort of 2,172 patients over 5 years presenting with acute diarrhea to International Centre for Diarrhoeal Disease Research, Dhaka Hospital, Bangladesh, were assessed for clinical signs of dehydration. The percent difference between presentation and posthydration stable weight determined severe (≥ 9%), some (3-9%), or no (< 3%) dehydration. An ordinal regression model was derived using clinical signs and demographics and was then converted to a 13-point score to predict none (score of 0-3), some (4-6), or severe (7-13) dehydration. The Novel, Innovative Research for Understanding Dehydration in Adults and Kids (NIRUDAK) Score developed by our team included age, sex, sunken eyes, radial pulse, respiration depth, skin turgor, and vomiting episodes in 24 hours. Accuracy of the NIRUDAK Score for predicting severe dehydration, as measured by the area under the receiver operating characteristic curve, was 0.76 (95% confidence interval = 0.73-0.78), with a sensitivity of 0.78 and a specificity of 0.61. Reliability was also robust, with an Inter-Class Correlation Coefficient of 0.88 (95% confidence interval = 0.84-0.91). This study represents the first empirically derived and internally validated scoring system for assessing dehydration in children ≥ 5 years and adults with acute diarrhea in a resource-limited setting.

The Clinical Presentation of Culture-positive and Culture-negative, Quantitative Polymerase Chain Reaction (qPCR)-Attributable Shigellosis in the Global Enteric Multicenter Study and Derivation of a Shigella Severity Score: Implications for Pediatric Shigella Vaccine Trials

BACKGROUND

Shigella is a leading cause of childhood diarrhea and target for vaccine development. Microbiologic and clinical case definitions are needed for pediatric field vaccine efficacy trials.

METHODS

We compared characteristics of moderate to severe diarrhea (MSD) cases in the Global Enteric Multicenter Study (GEMS) between children with culture positive Shigella to those with culture-negative, quantitative polymerase chain reaction (qPCR)-attributable Shigella (defined by an ipaH gene cycle threshold <27.9). Among Shigella MSD cases, we determined risk factors for death and derived a clinical severity score.

RESULTS

Compared to culture-positive Shigella MSD cases (n = 745), culture-negative/qPCR-attributable Shigella cases (n = 852) were more likely to be under 12 months, stunted, have a longer duration of diarrhea, and less likely to have high stool frequency or a fever. There was no difference in dehydration, hospitalization, or severe classification from a modified Vesikari score. Twenty-two (1.8%) Shigella MSD cases died within the 14-days after presentation to health facilities, and 59.1% of these deaths were in culture-negative cases. Age <12 months, diarrhea duration prior to presentation, vomiting, stunting, wasting, and hospitalization were associated with mortality. A model-derived score assigned points for dehydration, hospital admission, and longer diarrhea duration but was not significantly better at predicting 14-day mortality than a modified Vesikari score.

CONCLUSIONS

A composite severity score consistent with severe disease or dysentery may be a pragmatic clinical endpoint for severe shigellosis in vaccine trials. Reliance on culture for microbiologic confirmation may miss a substantial number of Shigella cases but is currently required to measure serotype specific immunity.

Introducing rotavirus vaccine in eight sub-Saharan African countries: a cost-benefit analysis

BACKGROUND

Stimulated by the economic challenges faced by many sub-Saharan African countries and the changes in the rotavirus burden across these countries, this study aimed to inform the decision of health policy makers of eight sub-Saharan countries, who are yet to introduce the rotavirus vaccine as of Dec 31, 2020, on the health economic consequences of the introduction of the vaccine in terms of the costs and benefits.

METHODS

We did a cost-benefit analysis using a simulation-based decision-analytic model for children aged younger than 1 year, who were followed up to 259 weeks, in the Central African Republic, Chad, Comoros, Equatorial Guinea, Gabon, Guinea, Somalia, and South Sudan. Data were collected and analysed between Jan 13, 2020, and Dec 11, 2020. Cost-effectiveness analysis and budget impact analysis were done as secondary analyses. Four rotavirus vaccinations (Rotarix, Rotateq, Rotavac, and Rotasiil) were compared with no vaccination. The primary outcome was disability-adjusted life-years averted, converted to monetary terms. The secondary outcomes include rotavirus gastroenteritis averted, and rotavirus vaccine-associated intussusception. The primary economic evaluation measure was the benefit-cost ratio (BCR).

FINDINGS

For the modelling period, Jan 1, 2021, to Dec 31, 2030, we found that the benefits of introducing the rotavirus vaccine outweighed the costs in all eight countries, with Chad and the Central African Republic having the highest BCR of 19·42 and 11·36, respectively. Guinea had the lowest BCR of 3·26 amongst the Gavi-eligible countries. Equatorial Guinea and Gabon had a narrow BCR of 1·86 and 2·06, respectively. Rotarix was the optimal choice for all the Gavi-eligible countries; Rotasiil and Rotavac were the optimal choices for Equatorial Guinea and Gabon, respectively.

INTERPRETATION

Introducing the rotavirus vaccine in all eight countries, but with caution in Equatorial Guinea and Gabon, would be worthwhile. With the narrow BCR for Equatorial Guinea and Gabon, cautious, pragmatic, and stringent measures need to be employed to ensure optimal health benefits and cost minimisation of the vaccine introduction. The final decision to introduce the rotavirus vaccine should be preceded by comparing its BCR to the BCRs of other health-care projects.

FUNDING

Copenhagen Consensus Center and the Bill & Melinda Gates Foundation.

Diarrhoeal diseases in Soweto, South Africa, 2020: a cross-sectional community survey

Background

In South Africa, there are limited data on the burden of diarrhoea at a community level, specifically in older children and adults. This community survey estimated rates of and factors associated with diarrhoea across all ages and determined the proportion of cases presenting to healthcare facilities.

Methods

Households were enrolled from an existing urban health and demographic surveillance site. A household representative was interviewed to determine associated factors and occurrence of diarrhoea in the household, for all household members, in the past 2 weeks (including symptoms and health seeking behaviour). Diarrhoeal rate of any severity was calculated for < 5 years, 5–15 years and > 15 years age groups. Factors associated with diarrhoea and health seeking behaviour were investigated using binomial logistic regression.

Results

Diarrhoeal rate among respondents (2.5 episodes/person-year (95% CI, 1.8–3.5)) was significantly higher than for other household members (1.0 episodes/person-year (95% CI, 0.8–1.4); IRR = 2.4 (95% CI, 1.5–3.7) p < 0.001). Diarrhoeal rates were similar between age groups, however younger children (< 5 years) were more likely to present to healthcare facilities than adults (OR = 5.9 (95% CI, 1.1–31.4), p = 0.039). Oral rehydration solution was used in 44.8% of cases. Having a child between 5 and 15 years in the household was associated with diarrhoea (OR = 2.3 (95% CI, 1.3–3.9), p = 0.003) and, while 26.4% of cases sought healthcare, only 4.6% were hospitalised and only 3.4% of cases had a stool specimen collected. While the majority of cases were mild, 13.8% of cases felt they required healthcare but were unable to access it.

Conclusion

Diarrhoeal rate was high across all age groups in this community; however, older children and adults were less likely to present to healthcare, and are therefore underrepresented through facility-based clinical surveillance. Current diarrhoeal surveillance represents a fraction of the overall cases occurring in the community.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11470-9.

Cost-Effectiveness Analysis of Community Case Management of Childhood Diarrhea in Burundi

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of community case management (CCM) program of childhood diarrhea by providing oral rehydration salts and zinc through community health workers in Burundi.

METHODS

A cost-effectiveness analysis study using a Markov modeling approach was undertaken to assess the CCM program of diarrhea from both provider and societal perspectives. The CCM program was compared with the routine management of childhood diarrhea at health facilities. Primary data on the cost of childhood diarrhea management were collected. Both economic and health outcomes were assessed for a period of 5 years, and a discount rate of 3% was applied. One-way and probabilistic sensitivity analyses were performed.

RESULTS

The CCM program was found to be both less costly and more effective resulting to a negative value of incremental cost-effectiveness ratios, indicating that the program was dominant producing cost savings. Compared with the routine treatment of diarrhea at health facilities, the CCM program would avert 2749 additional disability-adjusted life years over a period of 5 years. The economic burden was reduced of US$1 056 699 and US$2 328 531 from the provider and societal perspectives, respectively. The cost-effectiveness estimates were mostly sensitive to the discount rate and the cost of outpatient visits at health facilities. The intervention remained dominant with a 100% probability of cost savings within 10 000 simulations of the sensitivity analysis.

CONCLUSIONS

Providing inexpensive diarrheal treatment (oral rehydration salts and zinc) in communities is an attractive cost-effective intervention. Evidence from this study should be used to scale up the coverage of this life- and cost-saving intervention.

Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study

The illness cost borne by households, known as out-of-pocket expenditure, was 74% of the total health expenditure in Bangladesh in 2017. Calculating economic burden of diarrhea of low-income urban community is important to identify potential cost savings strategies and prioritize policy decision to improve the quality of life of this population. This study aimed to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 17, 2015 to July 26, 2016. We used the World Health Organization (WHO) definition of three or more loose stool in 24 hours to enroll patients and enrolled 106 severe patients and 158 non-severe patients from Tongi General Hospital, local pharmacy and study community. The team enrolled patients between the first to third day of the illness (≤ 72 hours) and continued daily follow-up by phone until recovery. We considered direct and indirect costs to calculate cost-per-episode. We applied the published incidence rate to estimate the annual cost of diarrhea. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 [95% CI: 24.55, 30.23] (2,147 BDT), 17% of the average monthly income of the households. The average cost of illness for patient with non-severe diarrhea was US$ 6.36 [95% CI: 5.19, 7.55] (499 BDT), 4% of the average monthly income of households. A single diarrheal episode substantially affects financial condition of low-income urban community residents: a severe episode can cost almost equivalent to 4.35 days (17%) and a non-severe episode can cost almost equivalent to 1 day (4%) of household’s income. Preventing diarrhea preserves health and supports financial livelihoods.

The illness cost borne by households, known as out-of-pocket expenditure was 74% of the total health expenditure in Bangladesh in 2017. Most of the studies in Bangladesh that estimated the cost of diarrheal illness collected data from hospital patients and mostly targeted under-five children. Information on economic burden of diarrhea borne by households of low-income urban communities who commonly had ≤ 2 US$ dollar income per capita per day still remained unknown. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 2015 to July 2016 to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 (2,147 BDT) and non-severe diarrhea was US$ 6.36 (499 BDT). A single diarrheal episode substantially affects financial capability of the low-income urban community: a severe episode can cost 4.35 days (17%) and a non-severe episode can cost 1 day (4%) of income of a households. Preventing diarrhea preserves health and supports financial livelihoods.

Wa-1 Equine-Like G3P[8] Rotavirus from a Child with Diarrhea in Colombia

Rotavirus A (RVA) has been considered the main cause of diarrheal disease in children under five years in emergency services in both developed and developing countries. RVA belongs to the Reoviridae family, which comprises 11 segments of double-stranded RNA (dsRNA) as a genomic constellation that encodes for six structural and five to six nonstructural proteins. RVA has been classified in a binary system with Gx[Px] based on the spike protein (VP4) and the major outer capsid glycoprotein (VP7), respectively. The emerging equine-like G3P[8] DS-1-like strains reported worldwide in humans have arisen an important concern. Here, we carry out the complete genome characterization of a previously reported G3P[8] strain in order to recognize the genetic diversity of RVA circulating among infants in Colombia. A near-full genome phylogenetic analysis was done, confirming the presence of the novel equine-like G3P[8] with a Wa-like backbone for the first time in Colombia. This study demonstrated the importance of surveillance of emerging viruses in the Colombian population; furthermore, additional studies must focus on the understanding of the spread and transmission dynamic of this important RVA strain in different areas of the country.

Derivation of the first clinical diagnostic models for dehydration severity in patients over five years with acute diarrhea

Diarrheal diseases lead to an estimated 1.3 million deaths each year, with the majority of those deaths occurring in patients over five years of age. As the severity of diarrheal disease can vary widely, accurately assessing dehydration status remains the most critical step in acute diarrhea management. The objective of this study is to empirically derive clinical diagnostic models for assessing dehydration severity in patients over five years with acute diarrhea in low resource settings. We enrolled a random sample of patients over five years with acute diarrhea presenting to the icddr,b Dhaka Hospital. Two blinded nurses independently assessed patients for symptoms/signs of dehydration on arrival. Afterward, consecutive weights were obtained to determine the percent weight change with rehydration, our criterion standard for dehydration severity. Full and simplified ordinal logistic regression models were derived to predict the outcome of none (<3%), some (3-9%), or severe (>9%) dehydration. The reliability and accuracy of each model were assessed. Bootstrapping was used to correct for over-optimism and compare each model's performance to the current World Health Organization (WHO) algorithm. 2,172 patients were enrolled, of which 2,139 (98.5%) had complete data for analysis. The Inter-Class Correlation Coefficient (reliability) was 0.90 (95% CI = 0.87, 0.91) for the full model and 0.82 (95% CI = 0.77, 0.86) for the simplified model. The area under the Receiver-Operator Characteristic curve (accuracy) for severe dehydration was 0.79 (95% CI: 0.76-0.82) for the full model and 0.73 (95% CI: 0.70, 0.76) for the simplified model. The accuracy for both the full and simplified models were significantly better than the WHO algorithm (p<0.001). This is the first study to empirically derive clinical diagnostic models for dehydration severity in patients over five years. Once prospectively validated, the models may improve management of patients with acute diarrhea in low resource settings.

Assessment of episodes of pneumonia and diarrhea in vaccinated and unvaccinated children under 60 months of age

Objective:

To assess the episodes of pneumonia and diarrhea in vaccinated and unvaccinated children under 60 months of age.

Methods:

This descriptive cross-sectional study was carried out at Darul Sehat Hospital and SESSI, Karachi in the Department of Pediatrics from 1^st November 2018 to 3^rd February 2019. An interview based questionnaire was administered and selection of participants was done by convenience sampling. Total of 196 participants were selected for interview.

Results:

Total 196 participants were interviewed which included mothers of children between the age group of 1- 60 months. The questions were entered on the questionnaire after taking consent from the mothers. Among them, males were 98 (52.7%) and females were 88(47.3%). One hundred seventy two (88.7%) children were vaccinated for pneumococcal and rotavirus whereas unvaccinated children were 22(11.3%). There was an incidence of 66(63.5%) for loose watery diarrhea. In vaccinated children, grading of diarrhea was found to be severe cases as 30 (34.9%), moderate cases as 27 (31.4%) and mild cases as 29(33.7%). For unvaccinated children, severe cases were 12 (66.7%) and for mild and moderate cases were (11.1%) and 04(22.2%) respectively with p value of 0.035. As compared to their unvaccinated counterparts, the frequency of severe pneumonia was far less than cough and cold in vaccinated children (p<0.001).

Conclusion:

There is significant reduction in cases of severe pneumonia in children receiving pneumococcal vaccine as compared to children receiving Rota vaccine there is moderate reduction in cases of severe diarrhea. The overall coverage of Pneumococcal and Rota vaccines was higher in our sample population. Efforts should be made to increase the awareness of Rotavirus vaccination in order to have better coverage in future.

Randomized, Placebo-Controlled, Double-Blind and Open-Label Studies in the Treatment and Prevention of Acute Diarrhea With Enterococcus faecium SF68

Enterococcus faecium SF68® (SF68) is a licensed pharmaceutical for treatment and prevention of diarrhea in Austria, Italy and Switzerland. However, as for other probiotics, evidence for its efficacy is based on small to medium-sized studies. Four unpublished studies on the treatment of acute diarrhea and the prevention of antibiotic-associated diarrhea were analyzed: one randomized, double blind, placebo-controlled trial (RCT) for treatment (n = 1,143), one open-label study for treatment (n = 5,093), one RCT for prevention (n = 1,397) and one open-label study for prevention (n = 4,340). Patients in the treatment-arm and the open-label studies received SF68 (b.i.d. for the prevention studies, t.i.d. for the treatment trials) for 7 days. Primary end points were time to resolution of diarrhea (treatment) and percentage of development of diarrhea (prevention). The primary endpoint of the treatment study was met with a decreased time to resolution of diarrhea in SF68-treated patients compared to controls (median 3 vs. 4 days, p < 0.001). Time to resolution of secondary symptoms was also significantly reduced. Preventive treatment with SF68 was more effective than placebo with development of diarrhea in 8.6 vs. 16.2% (p < 0.001). Results from the open-label studies were consistent with the RCTs. The incidence of adverse events were low (1.1 and 1.4% in the RCT and 4.7 and 7.4% in the open-label studies). SF68 is effective and safe in the treatment of acute diarrhea and prevention of antibiotic-associated diarrhea.

Cost of illness for childhood diarrhea in low- and middle-income countries: a systematic review of evidence and modelled estimates

Background

Numerous studies have reported the economic burden of childhood diarrhea in low- and middle-income countries (LMICs). Yet, empirical data on the cost of diarrheal illness is sparse, particularly in LMICs. In this study we review the existing literature on the cost of childhood diarrhea in LMICs and generate comparable estimates of cost of diarrhea across 137 LMICs.

Methods

The systematic literature review included all articles reporting cost estimates of diarrhea illness and treatment from LMICs published between January 2006 and July 2018. To generate country-specific costs, we used service delivery unit costs from the World Health Organization’s Choosing Interventions that are Cost-Effective (WHO–CHOICE database). Non-medical costs were calculated using the ratio between direct medical and direct non-medical costs, derived from the literature review. Indirect costs (lost wages to caregivers) were calculated by multiplying the average GDP per capita per day by the average number of days lost to illness identified from the literature. All cost estimates are reported in 2015 USD. We also generated estimates using the IHME’s service delivery unit costs to explore input sensitivity on modelled cost estimates.

Results

We identified 25 articles with 64 data points on either direct or indirect cost of diarrhoeal illness in children aged < 5 years in 20 LMICs. Of the 64 data points, 17 were on the cost of outpatient care, 28 were on the cost of inpatient care, and 19 were unspecified. The average cost of illness was US$36.56 (median $15.73; range $4.30 – $145.47) per outpatient episode and $159.90 (median $85.85; range $41.01 – $538.33) per inpatient episode. Direct medical costs accounted for 79% (83% for inpatient and 74% for outpatient) of the total direct costs. Our modelled estimates, across all 137 countries, averaged (weighted) $52.16 (median $47.56; range $8.81 – $201.91) per outpatient episode and $216.36 (median $177.20; range $23.77 –$1225.36) per inpatient episode. In the 12 countries with primary data, there was reasonable agreement between our modelled estimates and the reported data (Pearson’s correlation coefficient = .75).

Conclusion

Our modelled estimates generally correspond to estimates observed in the literature, with a few exceptions. These estimates can serve as useful inputs for planning and prioritizing appropriate health interventions for childhood diarrheal diseases in LMICs in the absence of empirical data.

The cost of not breastfeeding: global results from a new tool

Evidence shows that breastfeeding has many health, human capital and future economic benefits for young children, their mothers and countries. The new Cost of Not Breastfeeding tool, based on open access data, was developed to help policy-makers and advocates have information on the estimated human and economic costs of not breastfeeding at the country, regional and global levels. The results of the analysis using the tool show that 595 379 childhood deaths (6 to 59 months) from diarrhoea and pneumonia each year can be attributed to not breastfeeding according to global recommendations from WHO and UNICEF. It also estimates that 974 956 cases of childhood obesity can be attributed to not breastfeeding according to recommendations each year. For women, breastfeeding is estimated to have the potential to prevent 98 243 deaths from breast and ovarian cancers as well as type II diabetes each year. This level of avoidable morbidity and mortality translates into global health system treatment costs of US$1.1 billion annually. The economic losses of premature child and women’s mortality are estimated to equal US$53.7 billion in future lost earnings each year. The largest component of economic losses, however, is the cognitive losses, which are estimated to equal US$285.4 billion annually. Aggregating these costs, the total global economic losses are estimated to be US$341.3 billion, or 0.70% of global gross national income. While the aim of the tool is to capture the majority of the costs, the estimates are likely to be conservative since economic costs of increased household caregiving time (mainly borne by women), and treatment costs related to other diseases attributable to not breastfeeding according to recommendations are not included in the analysis. This study illustrates the substantial costs of not breastfeeding, and potential economic benefits that could be generated by government and development partners’ investments in scaling up effective breastfeeding promotion and support strategies.

Colloidal Silicon Dioxide in Tablet form (Carbowhite) Efficacy in Patients with Acute Diarrhea: Results of Randomized, Double-Blind, Placebo-Controlled, Multi-Center Study

The acute diarrhea is a wide-spread disease. The prescription of enterosorbents is appropriate as a primary measure for the treatment of the acute diarrhea for effective prevention of the fluid and electrolyte loss, as well as method for symptom relief of the attack of the disease. Aim of the study - the antidiarrheal efficacy and safety study of high-dispersion silicon dioxide enterosorbent in tablet dosage form in patients with acute diarrhea. This was randomized, double-blind, placebo-controlled, 4-center study. Acute diarrhea was defined as three and more episodes of watery stool per day either during 48 hours or less before study entry in the patients having normal stool recently. It has been postulated that symptoms and signs of acute diarrhea have to be caused by direct infection of the gastrointestinal tract and did not associated with moderate-to-severe systemic states. 144 patients with established acute diarrhea were randomized into treatment group (enterosorbent “Carbowhite”, n = 120) or placebo group. Date collection including severity diarrhea, systemic symptoms was performed at baseline and daily during 7 days. Stool examination and serological assay were performed at baseline. The primary end points were declared as time to complete recovery from acute diarrhea. It has been found that the use of the siliceous enterosorbent (“Carbowhite”) allowed to reduce (p < 0.001) the treatment period averagely for 0.9 days (95% confidence interval 0.5–1.2 days) in comparison with placebo. Data of safety monitoring has revealed that both patient groups had negative stool culture, while initiation of antibiotic treatment was run more frequently in placebo group (8.3%) compared to investigational product group (4.1%, P = 0.044). The siliceous enterosorbent “Carbowhite” was well tolerated and reduced the recovery time of the acute episode of the diarrhea in the clinically significant form.

Impact of a teacher-led school handwashing program on children's handwashing with soap at school and home in Bihar, India

Handwashing with soap is an important preventive health behavior, and yet promoting this behavior has proven challenging. We report the results of a program that trained teachers to deliver a handwashing with soap behavior change program to children in primary schools in Bihar, India. Ten intervention schools selected along with ten nearby control schools, and intervention schools received the “School of Five” program promoting handwashing with soap using interactive stories, games, and songs, behavioral diaries to encourage habit formation, and public commitment. Households with children aged 8–13 attending the nearby school were enrolled in the study. Handwashing with soap was measured using sticker diaries before eating and after defecation 4 weeks after the intervention was completed. Children in the treatment reported 15.1% more handwashing with soap on key occasions (35.2%) than those in the control group (20.1%) (RR: 1.77, CI: (1.22, 2.58), p = .003). There was no evidence that handwashing with soap after defecation was higher in the treatment group than the control group (RR: 1.18, CI: (0.88, 1.57), p = .265), but there was strong evidence that handwashing with soap was greater in the treatment than in the control before eating (RR: 2.68, 95% CI: (1.43, 5.03), p = .002). Rates of handwashing increased both at home (RR: 1.63, CI: 1.14, 2.32), p = .007) and at school (RR: 4.76, 95% CI: (1.65, 17.9), p = .004), though the impact on handwashing with soap at key occasions in schools was much higher than at home. Promoting handwashing with soap through teachers in schools may be an effective way to achieve behavior change at scale.

Geographical Variations and Factors Associated with Childhood Diarrhea in Tanzania: A National Population Based Survey 2015-16

Background

Diarrhea remains the leading cause of morbidity and mortality among under 5 children in low- and middle-income countries. In Tanzania, diarrhea remains one of the major public health problems. This study aimed to investigate spatial variations and the factors correlated with diarrhea in under five children.

Methods

This is a secondary data analysis using data from the population-based cross section Tanzanian Demographic and Health Survey 2015–16 data. Spatial analysis was done using the Bernoulli model from SaTScan™ software, and a generalized linear mixed model was used to identify the factors associated with childhood diarrhea.

Results

The overall reported prevalence of childhood diarrhea for the under five children in Tanzania was 12.1% (95%CI 11.3%–12.9%). The SaTScan spatial statics analysis revealed that diarrhea in children was not random. The odds of diarrhea were 7.35 times higher (AOR= 7.35; 95%CI: 5.29, 10.22) among children in the 6–11 months age group compared to children within the 48–59 months of age. As mother's age increased, the risk of diarrhea for the under five children decreased whereas the highest risk of diarrhea was observed in the two rich income brackets richer (AOR=1.70, 95%CI=1.30, 2.22), and richest (AOR= 1.05, 95%CI=1, 1.09). The odds of diarrhea were 1.25 times higher (AOR=1.25, 95%CI=1.06, 1.46) among children with unsafe stool disposal compared to those with safe disposal.

Conclusion

The socio-demographic factors associated with diarrhea among children were mother's age in years, current age of the child, wealth index and child stool disposal.

The Cholera Phone: Diarrheal Disease Surveillance by Mobile Phone in Bangladesh

Existing methodologies to record diarrheal disease incidence in households have limitations due to a high-episode recall error outside a 48-hour window. Our objective was to use mobile phones for reporting diarrheal episodes in households to provide real-time incidence data with minimum resource consumption and low recall error. From June 2014 to June 2015, we enrolled 417 low-income households in Dhaka, Bangladesh, and asked them to report diarrheal episodes to a call center. A team of data collectors then visited persons reporting the episode to collect data. In addition, each month, the team conducted in-home surveys on diarrhea incidence for a preceding 48-hour period. The mobile phone surveillance reported an incidence of 0.16 cases per person-year (95% CI: 0.13-0.19), with 117 reported diarrhea cases, and the routine in-home survey detected an incidence of 0.33 cases per person-year (95% CI: 0.18-0.60), the incidence rate ratio was 2.11 (95% CI: 1.08-3.78). During focus group discussions, participants reported a lack in motivation to report diarrhea by phone because of the absence of provision of intervening treatment following reporting. Mobile phone technology can provide a unique tool for real-time disease reporting. The phone surveillance in this study reported a lower incidence of diarrhea than an in-home survey, possibly because of the absence of intervention and, therefore, a perceived lack of incentive to report. However, this study reports the untapped potential of mobile phones in monitoring infectious disease incidence in a low-income setting.

Individual and community-level risk factors in under-five children diarrhea among agro-ecological zones in southwestern Ethiopia

Under-five children diarrhea remains a major public health problem in resource-limited areas, including Ethiopia, due to multiple risk factors. This study aimed to identify individual and community-level risk factors affecting under-five children diarrhea (UFCD) in five districts of the Bench Maji Zone, southwestern Ethiopia. A community-based cross-sectional study was conducted from February to April 2018. A total of 826 households were recruited from five randomly selected districts using stratified sampling. A multivariable logistic regression model was fitted to identify risk factors associated with UFCD. The prevalence of UFCD in the study area was found to be 18.3%. Children less than six months of age are more at risk for diarrhea (95% CI for AOR2.5;1.23-4.90). Most probably initiating supplementary feedings before six months of age is one of the main risk factor for diarrhea (95% CI for AOR 0.65; 0.45-0.98). Similarly, mothers with low educational status (95% CI for AOR 0.30; 0.10-0.84), limited knowledge of mothers' about diarrhea (95% CI for AOR 0.24; 0.15-0.40), absence of hand washing among mothers/caregivers at critical times (95% CI for AOR 4.6; 2.88-7.67), and sharing of the residence with domestic animals (95% CI for AOR 2.87, 1.75-4.67) were the predictors of UFCD at individual-level. Children living in semi pastoral areas (95% CI for AOR 0.22; 0.10-0.50) unvaccinated children for rotavirus prevention (95% CI AOR 5.22, 3.33-8.20), households obtaining water from unimproved sources (95% CI for AOR 2.53; 1.60-4.40), and households with unimproved latrine facilities (95% CI for AOR 0.60; 0.33-0.99) were the risk factors of UFCD at the community-level. The study revealed that UFCD is a critical health concern in southwestern Ethiopia, where integrated intervention approach at individual and community level could help to alleviate the problem. At individual level, behavioral change intervention on handwashing, exclusive breast-feeding before the age of six months, and awareness on diarrhea prevention methods are critical areas of intervention. Likewise, provision of safe and adequate water source combined with household water chlorination, and vaccination for rotavirus are interventions at community that need to be integrated with the individual-level of intervention. This could significantly contribute for the reduction of UFCD in the resource limited areas through intersectoral collaboration of the health and other sectors.

Cost-effectiveness analysis of a physician deployment program to improve access to healthcare in rural and underserved areas in the Philippines

OBJECTIVES

The objective of this study is to explore the cost-effectiveness of Doctor to the Barrios (DTTB), a physician deployment program in the Philippines.

DESIGN

Cost-effectiveness analysis using decision tree models with a lifetime time horizon and probabilistic sensitivity analysis.

SETTING

Societal and healthcare perspectives.

POPULATION

Hypothetical cohort of children under 5 years in two provinces (Aklan and Nueva Ecija) and in a representative rural municipality.

PARTICIPANTS

None.

INTERVENTIONS

DTTB's impact on paediatric pneumonia and diarrhoea outcomes compared with a scenario without DTTB.

MAIN OUTCOME MEASURES

Costs, effectiveness (in terms of lives saved and quality-adjusted life years (QALYs) gained) and incremental cost-effectiveness ratio (ICER).

RESULTS

DTTB is cost-effective in the two provinces that were included in the study from societal and healthcare perspectives. Looking at a representative rural municipality, base case analysis and probabilistic sensitivity analyses suggest that DTTB has an ICER of 27 192 per QALY gained from a societal perspective. From a healthcare perspective, the base case ICER of DTTB is Philippine pesos (PHP) 71 839 per QALY gained and PHP 2 064 167 per life saved, and 10 000 Monte Carlo simulations produced similar average estimates. The cost per QALY of DTTB from a healthcare perspective is lower than the WHO recommended willingness-to-pay threshold of 100% of the country's per-capita gross domestic product.

CONCLUSIONS

DTTB can be a cost-effective intervention, but its value varies by setting and the conditions of the municipality where it is implemented. By focusing on a narrow set of paediatric outcomes, this study has likely underestimated the health benefits of DTTB. Additional research is needed to understand the full extent of DTTB's impact on the health of communities in rural and remote areas. Future cost-effectiveness analysis should empirically estimate various parameters and include other health conditions in addition to pneumonia and diarrhoea in children.

Combinations of Alchornea cordifolia, Cassytha filiformis and Pterocarpus santalinoides in diarrhoegenic bacterial infections

Objectives

This study examines the rationale, if any, behind combining the extracts from the fruits of Alchornea cordifolia and Pterocarpus santalinoides and aerial parts of Cassytha filiformis in the traditional treatment of diarrhoegenic bacterial infections.

Results

Four diarrhoegenic bacterial isolates: Salmonella typhi, Shigellae dysenteriae, Escherichia coli and Staphylococcus aureus were used and their antibiotic susceptibility screening showed that they were multi-antibiotic resistant. The extracts exhibited activity against all the test isolates with minimum inhibitory concentration values ranging from 3.125 to 12.5 mg/mL. From the checkerboard assay, the fractional inhibitory concentration indices showed that C. filiformis has antagonistic and indifference activities in combination with either P. santalinoides or A. cordifolia. This showed that the combination of extracts from the fruits of A. cordifolia and P. santalinoides and aerial parts of C. filiformis is counterproductive and invalidates any claim for positive results in the management of diarrhoegenic bacterial infections.

'Entamoeba histolytica' identified by stool microscopy from children with acute diarrhoea in Peru is not E. histolytica

Entamoeba histolytica is a rare but feared pathogen owing to its related morbidity and mortality. Physicians in an ambulatory clinic in Cusco noted frequent reports of E. histolytica diagnosed by microscopy. Other non-pathogenic species of Entamoeba have an identical microscopic appearance. To determine whether the organisms were actually E. histolytica, faecal specimens from children aged six months to three years with diarrhoea were tested by a species-specific ELISA for E. histolytica antigen. Although 19/73 patients (26.0%) were presumptively diagnosed with amoebiasis based on microscopy, none were confirmed by ELISA. Most cases diagnosed as E. histolytic by microscopy in Peru are not infected by the pathogenic species and are probably colonised by non-pathogenic amoeba such as Entamoeba dispar.

Developing a Novel Mobile Health (mHealth) Tool to Improve Dehydration Assessment and Management in Patients with Acute Diarrhea in Resource-Limited Settings

Dehydration due to diarrhea is one of the main causes of death worldwide, yet no clinical tools for accurately assessing and managing dehydration in patients with acute diarrhea have been created for low- and middle-income countries (LMICs). In 2012, Brown University's Department of Emergency Medicine began partnering with the International Centre for Diarrhoeal Disease, Bangladesh in order to address some of these gaps. Out of this partnership, the DHAKA Score, a clinical diagnostic model for assessing dehydration in children under five years of age with acute diarrhea, was developed. Building upon the success of the DHAKA Study, researchers at both institutions have launched the NIRUDAK Study earlier this year to develop and validate similar age-specific clinical diagnostic models yet shifting the patient population to those over five. Improving diagnostic approaches and fluid management may reduce unnecessary utilization of already limited healthcare resources as well as the morbidity and mortality that occurs due to misdiagnosis.

Prevalence and associated factors of safe and improved infant and young children stool disposal in Ethiopia: evidence from demographic and health survey

BACKGROUND

Infant and young children stools are often considered innocuous, and are not disposed of safely despite having a higher pathogen load than adult feces. In Ethiopia, sanitary management of young children's stool is often overlooked and transmission of fecal-oral diseases is still a significant health burden. The study, therefore, describes the prevalence and associated factors of safe and improved child stool disposal.

METHODS

Data from the fourth round of the Ethiopian Health and Demographic Survey (EDHS) conducted in 2016 was used for this analysis. Descriptive statistics were computed. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with safe and improved child stool disposal.

RESULTS

The prevalence of safe and improved child stool disposal in Ethiopia was 36.9% (95%CI: 33.4-40.5%) and 5.3% (95%CI: 4.3-6.5%) respectively. There was regional variation in the prevalence of safe and improved child stool disposal. The odds of safe stool disposal among households with richest wealth index had 4.54 (AOR: 4.54; 95%CI: 2.89-7.12), richer 3.64 (AOR: 3.64; 95%CI: 2.46-5.38), middle 3.26 (AOR: 2.26; 95%CI: 2.27-4.68), and poorer 1.93 (AOR: 1.93; 95%CI: 1.39-2.68) times higher odds of practicing safe child stool disposal than households with poorest wealth index. Similarly, households found in richest, richer, middle, and poorer wealth index had also (AOR: 20.23; 95%CI: 8.59-47.66), (AOR: 12.53; 95%CI: 5.59-28.10) (AOR: 4.91; 95%CI: 1.92-12.55), and (AOR: 4.50; 95%CI: 2.06-9.84) higher odds of practicing improved child stool disposal than households from poorest wealth index respectively. The odds of safe child stool disposal were higher among households whose children age between 6 and 11 months (AOR: 1.57; 95%CI: 1.17-2.09), 12-17 months (AOR: 1.39; 95%CI: 1.00-1.95), and 18-23 months (AOR: 1.43; 95%CI: 1.03-1.99) than households whose children age between 0 and 5 months. The odds of safe child stool disposal were 1.31 (AOR: 1.31; 95%CI: 1.00-1.72) and 1.44 (AOR: 1.44; 95%CI: 1.04-2.01) times higher among mothers whose age between 25 and 34 and greater than 34 years compared to mothers whose age between 15 and 24 years, respectively. In addition, children's stools are more likely to be disposed of safely in urban households than in rural households (AOR: 3.12; 95%CI: 1.86-5.22). The present study also revealed households with access to improved sanitation facilities fail to use them for disposal of child stool (AOR: 0.99; 95% CI: 0.67-1.45).

CONCLUSIONS

The prevalence of safe and improved child stool disposal in Ethiopia was found to be very low. Household socio-demographic and economic determinate were the key factors associated with child stool disposal. Appropriate strategic interventions to ensure safe and improved child stool disposal in Ethiopia is necessary. In addition, integrating child stool management into the existing sanitation interventions programs should be strongly recommended.

Prevalence of diarrheal illness and healthcare-seeking behavior by age-group and sex among the population of Gaza strip: a community-based cross-sectional study

BACKGROUND

In the Gaza strip, diarrhea is one of main reasons for children visiting primary healthcare centers. Hence, we investigate predictors of the diarrheal illness and health care-seeking behavior among different age groups.

METHODS

This community-based cross-sectional survey was conducted from August 2017 to June 2018 among 1857 households. A pretested structured questionnaire included information about socio-demographic, sanitation, hygiene, source of water, diarrheal illness, and seeking healthcare in households was administered to head of household. To achieve representativeness for the five Gaza's governorates, a cluster random sampling was applied.

RESULTS

Of the 1857 household's heads, 421 (22.7%) reported an episode of diarrhea during the 48 h preceding the interview resulting an overall prevalence rate of 3.8 per 100 individuals. The prevalence of diarrhea was statistical significant greater in males (5.4/100) compared to females (1.3/100) in all age groups (p <  0.05). Socio-demographic, economic, water, sanitation, and hygiene factors were predictors of the diarrheal illness and seeking of non-professional healthcare for diarrhea illness treatment among. A transition behavior from professional to non-professional and vice versa in seeking healthcare in each diarrheal episode was found.

CONCLUSIONS

We recommend improving the status of water, sanitation, and hygiene in the Gaza strip's households to reduce diarrhea among the population of Gaza strip. Community sensitization about the importance of seeking care at primary health centers because treatment of children is available for free or in low costs.

Budget Impact Analysis of Rotavirus Vaccine Adoption in the Childhood Immunization Schedule of Iran

OBJECTIVES

To examine the budget impact of introducing the RotaTeq® vaccine (Merck and Co Inc, West Point, PA) to the national immunization program in Iran.

METHODS

The pre- and postvaccine introduction costs were compared. The total annual costs included the vaccination and diarrhea treatment costs. The health outcome was the estimated annual cases of the disease. To evaluate the net budget impact, the annual prevaccine introduction cost was reduced from the postvaccine introduction cost. The sensitivity analysis was done to reduce the uncertainties.

RESULTS

The total cost of vaccination for 5 years would be more than $184 million. Nevertheless, the financial savings would be about $45 million and $7.5 million because of the reduction in the number of patients after vaccination in inpatient and outpatient sectors, respectively. So the incremental cost would be $131 450 210 during 5 years of immunization.

CONCLUSIONS

The results show that the inclusion of rotavirus vaccine in the national vaccination program would have a significant effect on health budgets and would raise government expenditure.

Cost of Caregivers for Treating Hospitalized Diarrheal Patients in Bangladesh

INTRODUCTION

Diarrheal diseases are a global public health problem and one of the leading causes of mortality, morbidity and economic loss. The objective of the study is to estimate the economic cost of caregivers and cost distribution per diarrheal episodes in Bangladesh.

METHODS

This was a cross-sectional hospital-based study conducted in public hospitals in Bangladesh. A total of 801 diarrheal patients were randomly selected and interviewed during January to December 2015. Simple descriptive statistics including frequencies, percentage, mean with 95% CI and median are presented.

RESULTS

The overall average cost of caregivers was BDT 2243 (US$ 28.58) while only BDT 259 (US$ 3.29) was spent as out of pocket payments. Caregivers mostly spent money (US$ 1.63) for food, lodging, utility bills, and other lump sum costs followed by the transportation costs (US$ 1.57). The caregivers spent more (US$ 44.45) when they accompanied the patients who were admitted in inpatients care and almost 3.6 times higher than for out-patients care (US$ 12.42).

CONCLUSIONS

The study delivers an empirical evidence to the health-care programmers and policy makers about the economic cost of caregivers during diarrheal treatment care, which should be accounted for in designing future diarrheal prevention programme.

Clinical application of a multiplex genetic pathogen detection system remaps the aetiology of diarrhoeal infections in Shanghai

Background

Culture-based diagnostic methods cannot achieve rapid and precise diagnoses for the identification of multiple diarrhoeal pathogens (DPs). A high-throughput multiplex genetic detection system (HMGS) was adapted and evaluated for the simultaneous identification and differentiation of infectious DPs and a broad analysis of DP infection aetiology.

Results

DP-HMGS was highly sensitive and specific for DP detection compared with culture-based techniques and was similar to singleplex real-time PCR. The uniform level of sensitivity of DP-HMGS for all DPs allowed us to remap the aetiology of acute diarrhoeal infections in Shanghai, correcting incidences of massively underdiagnosed DP species with accuracy approaching that of sequencing-based methods. The most frequent DPs were enteropathogenic Escherichia coli, rotavirus and Campylobacter jejuni. DP-HMGS detected two additional causes of infectious diarrhoea that were previously missed by routine culture-based methods: enterohemorrhagic E. coli and Yersinia enterocolitica. We demonstrated the age dependence of specific DP distributions, especially the distributions of rotavirus, intestinal adenovirus and Clostridium difficile in paediatric patients as well as those of dominant bacterial infections in adults, with a distinct “top 3” pattern for each age group. Finally, the multiplexing capability and high sensitivity of DP-HMGS allowed the detection of infections co-induced by multiple pathogens (approximately 1/3 of the cases), with some DPs preferentially co-occurring as infectious agents.

Conclusions

DP-HMGS has been shown to be a rapid, specific, sensitive and appropriate method for the simultaneous screening/detection of polymicrobial DP infections in faecal specimens. Widespread use of DP-HMGS is likely to advance routine diagnostic and clinical studies on the aetiology of acute diarrhoea.

Electronic supplementary material

The online version of this article (10.1186/s13099-018-0264-7) contains supplementary material, which is available to authorized users.

Determinants of childhood diarrhea in West Gojjam, Northwest Ethiopia: a case control study

Introduction

Childhood diarrhea is a global public health problem that affects both developed and developing countries including Ethiopia. The objective of this study was to assess determinants of childhood diarrhea among children under-five years of age in West Gojjam Zone, northwest Ethiopia.

Methods

A community-based case control study was conducted in four districts of West Gojjam in the northwest of Ethiopia from July to August, 2015. A randomly selected sample of 118 cases and 351 controls who met the inclusion criteria were included in this study. Data were collected using a structured questionnaire through face to face interview. Independent variables which had p-value less than 0.2 at an unadjusted model were candidate for the final model. Adjusted odds ratio was used to control confounding effects and to determine predictors of an outcome.

Results

Unimproved water sources (AOR, 1.88; 95 % CI: 1.17-3.03), lack of hand washing at critical times (AOR, 2.38; 95 % CI: 1.42-3.99) and a deepening method to take water from a water storage container (AOR, 2.11; 95 % CI: 1.28-3.47), presence of two or more young siblings (AOR, 4.15; 95 % CI: 2.57-6.70), rural residence (AOR,2.11 95 % CI: 2.21-3.68), and not using latrine for disposal of child feces (AOR, 1.90; 95 % CI: 1.12-3.22) were predictors of diarrhea among children under the age of five.

Conclusion

The majority of the causes of childhood diarrhea in the study area were preventable. Thus, health extension workers should give tailored health information to mothers or caregivers on the importance of sanitation, personal and environmental hygiene and drinking water handling methods.

Speciation, clinical profile & antibiotic resistance in Aeromonas species isolated from cholera-like illnesses in a tertiary care hospital in north India

Background & objectives:

Aeromonas species have been reported to cause various illnesses in humans such as wound infections, septicaemia, peritonitis and pneumonia. Their role in causation of cholera-like illness is also being increasingly recognized. This retrospective study was done to know the presence of Aeromonas as a cause of acute diarrhoea in a tertiary care hospital and to find the common species of Aeromonas causing diarrhoea and their antibiotic susceptibility patterns.

Methods:

Fifty isolates of Aeromonas were obtained over a period of 15 yr from 2000 to 2014 from patients of suspected acute gastroenteritis resembling cholera. Biotyping was done for 35 of these isolates available in culture collection, based on a panel of 13 biochemical reactions. Antibiogram was put up for all of these isolates by disk diffusion methods and interpreted according to the Clinical and Laboratory Standards Institute guidelines.

Results:

Of the 50 patients of Aeromonas-related acute gastroenteritis, 13 (26%) had typical features of cholera with rice water stools and severe dehydration. Eight patients (16%) had dysentery-like picture. One patient died of severe dehydration and septicaemia. The most common species were found to be Aeromonas caviae (34%) followed by Aeromonas veronii biovar veronii (29%), Aeromonas veronii biovar sobria (26%) and Aeromonas hydrophila (9%). All tested isolates were uniformly susceptible to cefepime, amikacin, azithromycin and meropenem; 14 per cent were susceptible to amoxicillin, 32 per cent to nalidixic acid, 60 per cent to co-trimoxazole, 54 per cent to ciprofloxacin, 60 per cent to ofloxacin, 74 per cent to chloramphenicol, 76 per cent to ceftriaxone, 74 per cent to cefotaxime, 88 per cent to gentamicin and 86 per cent to furoxone.

Interpretation & conclusions:

Aeromonas is an important, often neglected pathogen capable of causing a variety of gastrointestinal tract symptoms such as acute diarrhoea and dysentery and may even mimic cholera. It is, therefore, pertinent to recognize this pathogen as an important agent in the causation of severe diarrhoea.

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.

Economic costs of hospitalized diarrheal disease in Bangladesh: a societal perspective

BACKGROUND

Diarrheal diseases are a major threat to human health and still represent a leading cause of morbidity and mortality worldwide. Although the burden of the diarrheal diseases is much lower in developed countries, it is a significant public health problem in low and middle-income countries like Bangladesh. Though diarrhea is preventable and managed with low-cost interventions, it is still the leading cause of morbidity according to the patient who sought care from public hospitals in Bangladesh indicating that significant resources are consumed in treating those patients. The aim of the study is to capture the inpatients and outpatient treatment cost of diarrheal disease and to measure the cost burden and coping mechanisms associated with diarrheal illness.

METHODS

This study was conducted in six randomly selected district hospitals from six divisions (larger administrative units) in Bangladesh. The study was performed from the societal perspective which means all types of costs were identified, measured and valued no matter who incurred them. Cost analysis was estimated using the guideline proposed by the World Health Organization for estimating the economic burden of diarrheal diseases. The study adopted quantitative techniques to collect the household and hospital level data including structured and semi-structured questionnaires, observation checklists, analysis of hospital database, telephone interviews and compilation of service statistics.

RESULTS

The average total societal cost of illness per episode was BDT 5274.02 (US $ 67.18) whereas the average inpatient and outpatient costs were BDT 8675.09 (US $ 110.51) and BDT 1853.96 (US $ 23.62) respectively. The cost burden was significantly highest for poorest households, 21.45% of household income, compared to 4.21% of the richest quintile.

CONCLUSIONS

Diarrheal diseases continue to be an overwhelming problem in Bangladesh. The economic impact of any public health interventions (either preventive or promotive) that can reduce the prevalence of diarrheal diseases can be estimated from the data generated from this study.