Low rate of infectious enterocolitis in allogeneic stem cell transplant recipients with acute diarrhea: A prospective study by the GETH-TC

Acute diarrhea is a common and debilitating complication in recipients of an allogeneic hematopoietic stem cell transplantation (HCT). In this prospective, observational, and multi-center study we examined all episodes occurring in the first 6 months of 142 consecutive adult patients who underwent a reduced-intensity conditioning (RIC) HCT in 10 Spanish tertiary University Hospitals. Fifty-four patients (38%) developed a total of 75 acute diarrhea episodes. The median time from HCT to the first episode was 38 days (4-157). The main cause of enterocolitis was lower GI-aGVHD (38%), followed by infections (21%) and drug-related toxicity (8%). Causative infectious causes were identified in only 16/75 episodes (21%). C. difficile-related infection (CDI) was the most common infectious agent with an incidence and recurrence of 13% and 2%, respectively. With a median follow-up for survivors of 32 months, the NRM and the overall survival (OS) at 1 year, were 20% (95% C.I.: 14-28%) and 69% (95% C.I.: 61-77%), respectively. Development of enterocolitis was not associated with higher NRM (p = 0.37) or worse OS (p = 0.9). This real-life study confirms that the diagnosis and management of acute diarrhea in the early stages after HCT is challenging. Nosocomial infections, seem to be relatively uncommon, probably due to more rational use of antibiotics.

Incidence and predictors of severe acute malnutrition mortality in children aged 6-59 months admitted at Pawe general hospital, Northwest Ethiopia

Background

Severe acute malnutrition (SAM) is defined as a weight-for-height < -3z scores of the median WHO growth standards, or visible severe wasting or the presence of nutritional edema. SAM related mortality rates in under-five children are well documented in Ethiopia but data on their predictors are limited. We aimed to document factors associated with SAM related mortality to inform better inpatient management.

Methods

A facility-based retrospective cohort study was conducted among children admitted due to SAM at Pawe General Hospital, Northwest Ethiopia, from the 1^st of January 2015 to the 31^st of December 2019. Data from the records of SAM children were extracted using a standardized checklist. Epi-Data version 3.2 was used for data entry, and Stata version 14 was used for analysis. Bi-variable and multivariable Cox regression analyses were conducted to identify predictors of mortality. Variables with P<0.05 were considered significant predictors of mortality.

Results

Five-hundred sixty-eight SAM cases were identified of mean age was 27.4 (SD± 16.5) months. The crude death rate was 91/568 (16.02%) and the mean time to death was determined as 13 (±8) days. Independent risk factors for death were: (i) vomiting AHR = 5.1 (1.35–21.1, p = 0.026), (ii) diarrhea AHR = 2.79 (1.46–5.4, p = 0.002), (iii) needing nasogastric therapy AHR = 3.22 (1.65–6.26, p = 0.001), (iv) anemia AHR = 1.89 (1.15–3.2, p = 0.012), and (v) being readmitted with SAM AHR = 1.7 (1.12–2.8, p = 0.037).

Conclusion

SAM mortality was high in under-five children in our setting. The identified risk factors should inform treatment and prevention strategies. Improved community health education should focus on healthy nutrition and seeking early treatment. Inpatient mortality may be reduced by stricter adherence to treatment guidelines and recognizing early the key risk factors for death.

Effect of 3 Days of Oral Azithromycin on Young Children With Acute Diarrhea in Low-Resource Settings: A Randomized Clinical Trial

Importance

World Health Organization (WHO) guidelines do not recommend routine antibiotic use for children with acute watery diarrhea. However, recent studies suggest that a significant proportion of such episodes have a bacterial cause and are associated with mortality and growth impairment, especially among children at high risk of diarrhea-associated mortality. Expanding antibiotic use among dehydrated or undernourished children may reduce diarrhea-associated mortality and improve growth.

Objective

To determine whether the addition of azithromycin to standard case management of acute nonbloody watery diarrhea for children aged 2 to 23 months who are dehydrated or undernourished could reduce mortality and improve linear growth.

Design, Setting, and Participants

The Antibiotics for Children with Diarrhea (ABCD) trial was a multicountry, randomized, double-blind, clinical trial among 8266 high-risk children aged 2 to 23 months presenting with acute nonbloody diarrhea. Participants were recruited between July 1, 2017, and July 10, 2019, from 36 outpatient hospital departments or community health centers in a mixture of urban and rural settings in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Each participant was followed up for 180 days. Primary analysis included all randomized participants by intention to treat.

Interventions

Enrolled children were randomly assigned to receive either oral azithromycin, 10 mg/kg, or placebo once daily for 3 days in addition to standard WHO case management protocols for the management of acute watery diarrhea.

Main Outcomes and Measures

Primary outcomes included all-cause mortality up to 180 days after enrollment and linear growth faltering 90 days after enrollment.

Results

A total of 8266 children (4463 boys [54.0%]; mean [SD] age, 11.6 [5.3] months) were randomized. A total of 20 of 4133 children in the azithromycin group (0.5%) and 28 of 4135 children in the placebo group (0.7%) died (relative risk, 0.72; 95% CI, 0.40-1.27). The mean (SD) change in length-for-age z scores 90 days after enrollment was -0.16 (0.59) in the azithromycin group and -0.19 (0.60) in the placebo group (risk difference, 0.03; 95% CI, 0.01-0.06). Overall mortality was much lower than anticipated, and the trial was stopped for futility at the prespecified interim analysis.

Conclusions and Relevance

The study did not detect a survival benefit for children from the addition of azithromycin to standard WHO case management of acute watery diarrhea in low-resource settings. There was a small reduction in linear growth faltering in the azithromycin group, although the magnitude of this effect was not likely to be clinically significant. In low-resource settings, expansion of antibiotic use is not warranted. Adherence to current WHO case management protocols for watery diarrhea remains appropriate and should be encouraged.

Trial Registration

ClinicalTrials.gov Identifier: NCT03130114.

Taking care of a diarrhea epidemic in an urban hospital in Bangladesh: Appraisal of putative causes, presentation, management, and deaths averted

Background

In April 2018, a diarrhea epidemic broke out in Dhaka city and adjoining areas, which continued through May. The Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), a dedicated diarrheal disease hospital, had a large upsurge in patient visits during the epidemic. An enhanced understanding of the epidemiology of this epidemic may help health-related professionals better prepare for such events in the future. This study examined the microbial etiology and non-pathogen factors associated with diarrhea during the epidemic. The study also evaluated the patients’ presentation and clinical course and estimated the potential mortality averted by treating patients during the epidemic.

Methodology/Principal findings

Data from the patients who were treated at Dhaka Hospital during the diarrhea epidemic between April 2 and May 12, 2018 and were enrolled into the Diarrheal Disease Surveillance System (DDSS) at icddr,b were compared with the DDSS-enrolled patients treated during the seasonally-matched periods in the flanking years using logistic regression. icddr,b Dhaka Hospital treated 29,212 diarrheal patients during the 2018 epidemic period (and 25,950 patients per comparison period on average). Vibrio cholerae was the most common pathogen isolated (7,946 patients; 27%) and associated with diarrhea during the epidemic (adjusted odds ratio [AOR] 1.5, 95% CI: 1.1–2.0). The interaction of Vibrio cholerae with ETEC (AOR 2.7, 95% CI: 1.3–5.9) or Campylobacter (AOR 2.4, 95% CI: 1.1–5.1) was associated with further increased odds of diarrhea during the epidemic. In children under five years old, rotavirus was the most common pathogen (2,029 patients; 26%). Those who were adolescents (AOR 2.0, 95% CI: 1.3–3.1) and young adults (AOR 1.9, 95% CI: 1.4–2.5) compared to children younger than five years, resided within a 10 km radius of Dhaka Hospital (AOR 1.6, 95% CI: 1.1–2.2) compared to those living outside 20 km, borrowed money or relied on aid to pay for the transport to the hospital (AOR 1.6, 95% CI: 1.2–2.0), used tap water (AOR 1.8, 95% CI: 1.4–2.4) for drinking compared to tubewell water, and disposed of the solid waste directly outside the house (AOR 4.0, 95% CI: 2.7–5.9) were more likely to present with diarrhea during the epidemic. During the epidemic, patients were more likely to present with severe dehydration (odds ratio [OR] 1.6, 95% CI: 1.3–2.0) and require inpatient admission (OR 2.5, 95% CI: 1.9–3.3), intravenous rehydration (OR 1.7, 95% CI: 1.4–2.1), and antibiotics (OR 2.2, 95% CI: 1.8–2.7). The in-hospital case fatality rate was low (13 patients; 0.04%), and the hospital averted between 12,523 and 17,265 deaths during the epidemic.

Conclusions/Significance

Vibrio cholerae played the primary role in the 2018 diarrhea epidemic in Dhaka. Campylobacter, enterotoxigenic Escherichia coli, and rotavirus had a secondary role. Adolescents and adults, residents of the metropolitan area, and those who were relatively poor and lacked safe water, sanitation, and hygiene (WASH) practices comprised the most vulnerable groups. Despite the increased disease severity during the epidemic, the case fatality rate was less than 0.1%. icddr,b Dhaka Hospital saved as many as 17,265 lives during the epidemic.

We analyzed records of patients presenting during a diarrhea epidemic in 2018 to the world’s largest diarrhea treatment hospital in Dhaka, Bangladesh. Patients presenting during the epidemic and the non-epidemic periods were compared at multiple levels. We found that Vibrio cholerae played a crucial role in the diarrhea epidemic. Campylobacter, enterotoxigenic Escherichia coli, and rotavirus had a secondary role. Adolescents and adults, residents of the Dhaka metropolitan area, and those who were relatively poor and lacked safe water, sanitation, and hygiene (WASH) practices were more vulnerable to the epidemic. Patients had increased disease severity during the epidemic, but the death rate was extremely low in the hospital. icddr,b Dhaka Hospital saved several thousand lives by taking care of diarrhea patients during the epidemic.

Serum Albumin to Creatinine Ratio as Predictor for 30-Day All-Cause Mortality in Patients with Clostridium Di!cile-Associated Diarrhea

BACKGROUND

Clostridium difficile-associated diarrhea (CDAD) is a significant cause of mortality and morbidity in hospitalized patients. Several scores have developed in order to assess the severity of CDAD.

OBJECTIVE

To determine the role of the serum albumin to creatinine ratio (sACR) in predicting the 30-day all-cause mortality of patients with CDAD in comparison with other known severity scores of CDAD.

METHODS

A retrospective study was conducted at Baruch-Padeh Medical Center from January 2014 to December 2019. Patients with CDAD were recruited from Internal Medicine Departments, Intensive Care Units, and Surgical Departments. Data on demographic characteristics, clinical signs, underlying conditions, and several risk factors for CD infection were collected. We compared between severity scores of CDAD, such as ATLAS, the CDAD severity score, and the sACR in predicting the 30-day all-cause mortality in hospitalized patients with CDAD.

RESULTS

116 patients with CDAD were included. The ATLAS, CDAD scores, and sACR were calculated for all patients. The mean age of the participants was 71.4±16.4 years. 57.7% were of female gender. Fifty-two (44.8%) died within 30 days. An ATLAS score of ≥8 points had a 3.6-fold higher risk of 30-day all-cause mortality in hospitalized patients with CDAD (HR 3.6, 95% CI 3.28-3.99, p=0.001), a CDAD score of ≥5 points (HR 1.1, 95% CI 0.91-1.42, p=0.05), and a sACR≤3.4 (HR 1.5, 95%CI 1.25-1.82, p=0.04).

CONCLUSION

In this study, it was found that a sACR≤3.4 could predict the 30-day all-cause mortality in patients with CDAD.

Prevalence of common symptoms of neonatal illness in Northwest Ethiopia: A repeated measure cross-sectional study

BACKGROUND

The neonatal period is the most vulnerable stage of life. In Ethiopia, neonatal illness is common and the reduction in neonatal mortality is not as significant as for under-five mortality.

OBJECTIVES

To determine the prevalence and factors associated with neonatal illness symptoms reported by mothers delivering in health facilities in Northwest Ethiopia.

METHODS

A repeated measure cross-sectional study design was employed to collect data from 358 randomly selected deliveries in 11 health facilities from November 2018 to March 2019. A pretested and interviewer-administered structured questionnaire adapted from the literature was employed to record neonatal outcomes (illnesses and/or deaths) at birth, 24 hours, 7th, 14th and 28th day from birth. Cleaned data was exported to STATA version 14 software for analysis. Multilevel analysis was used to identify individual and facility-level characteristics associated with neonatal illness symptoms.

RESULTS

The prevalence of neonatal illness symptoms was 27.8% (95% CI; 23.2, 32.8) of the 338 babies born alive and the neonatal mortality rate was 41/1000 live births (14/338). The most common symptoms or conditions of neonatal illness reported by mothers' in the study area were possible serious bacterial infections (95.8%, 90/94), localized bacterial infections (43.6%, 41/94), low birth weight (23.4%, 22/94), diarrhea (18.1%, 17/94), prematurity (14.9%, 14/94), and jaundice (7.5%, 7/94). Among the babies who died, neonates who had possible serious bacterial infections, low birth weight, localized bacterial infections, and prematurity took the highest proportions with 100% (14/14), 64.3% (9/14), 50% (7/14), and 42.9% (6/14), respectively. Having a maximum of 3 children (AOR = 1.96; 95% CI = 1.1-3.6), having twins or triplets during pregnancy (AOR = 2.43; 95% CI = 1.1-6.1), and lack of antenatal counseling (AOR = 1.83; 95% CI = 1.1-3.3) were among the maternal factors associated with neonatal illness. Having low birth length (AOR = 7.93; 95% CI = 3.6-17.3), and having a poor breastfeeding quality (AOR = 2.37; 95% CI = 1.4-4.0) were found to be the neonatal factors associated with neonatal illness.

CONCLUSIONS

This study indicated a high prevalence of neonatal illness symptoms in Northwest Ethiopia. Therefore, early detection, referral and better management of symptoms or conditions with a high mortality, like sepsis and low birth weight are compulsory to save the lives of many neonates. Strengthening the health extension programme to improve antenatal care service utilization and breastfeeding quality of neonates among postpartum women is crucial.

Clinical and laboratory characteristics of children under five hospitalized with diarrhea and bacteremia

BACKGROUND

Diarrhea is one of the leading causes of mortality in children under five globally. When it is associated with bacteremia, mortality is even higher. However, bacteraemia in diarrheal children has gained little attention in spite of its deleterious impact in under-five mortality. So, we aimed to evaluate associated clinical and laboratory factors for death in under-five children hospitalized with both diarrhea and bacteremia.

METHODS

In this retrospective cross-sectional study, we used patients' electronic database of Dhaka Hospital of 'icddr,b', and enrolled all under-five children with diarrhea and bacterial growth in their blood samples on admission between June-2014 and May-2017. Clinical and laboratory characteristics were compared between those who died and who survived with a special attention to bacterial pathogens related to deaths and their sensitivity pattern.

RESULTS

In a total of 401 diarrheal children with bacteraemia, 45 (11%) died. Although Salmonella Typhi (34%) was the most predominant isolate followed by Staphylococcus species (16%) and Pseudomonas species (9%), children who died more often had E. coli (OR = 5.69, 95% CI = 2.42-13.39, p = <0.001) and Klebsiella bacteraemia (OR = 4.59, 95% CI = 1.84-11.46, p = 0.001) compared to those who survived. However, none of them was significantly associated with deaths in regression analysis when adjusted with other potential confounders. E. coli was 100% resistant to ampicillin, 41% to gentamicin, and 73% to ceftriaxone and Klebsiella species was 96% resistant to ampicillin, 42% to gentamicin, and 62% to ceftriaxone. Study children who died had significantly higher overall resistance pattern shown in World Health Organization (WHO) recommended one of the first line antibiotics in treating childhood sepsis such as ampicillin (80% vs. 50%, p = 0.001) and in second line antibiotic such as ceftriaxone (49% vs. 22%, p = 0.001) compared to the survivors. In logistic regression analysis, after adjusting for potential confounders, we found that clinical sepsis (aOR 3.79, 95% CI 1.60-8.96, p = 0.002), hypoxemia (aOR 4.20, 95% CI 1.74-10.12, p = 0.001), and hyperkalaemia (aOR 2.69, 95% CI 1.05-6.91, p = 0.039) were found to be independent predictors of deaths and receipt of sensitive antibiotic (aOR 0.42, 95% CI 0.18-0.99, p = 0.048) was revealed as the independent protective factor for deaths in this population.

CONCLUSION AND SIGNIFICANCE

The results of our data suggest that diarrheal children with bacteremia who died more often had gram negative bacteremia compared to those who survived and these pathogens are highly resistant to WHO recommended first line and second line antibiotics. The results further emphasize the critical importance of early identification of important clinical problems such as clinical sepsis, hypoxemia and hyperkalaemia in diarrheal children and treat them with potential sensitive antibiotic(s) in order to reduce bacteremia related mortality in children with diarrhea, especially in resource limited settings.

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

BACKGROUND

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

METHODS

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

FINDINGS

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

INTERPRETATION

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

FUNDING

Bill & Melinda Gates Foundation.

Determinants and patterns of care-seeking for childhood illness in rural Pune District, India

BACKGROUND

An estimated 1.2 million children under five years of age die each year in India, with pneumonia and diarrhea among the leading causes. Increasing care-seeking is important to reduce mortality and morbidity from these causes. This paper explores the determinants and patterns of care-seeking for childhood illness in rural Pune district, India.

METHODS

Mothers having at least one child <5 years from the study area of the Vadu Health and Demographic Surveillance System were enrolled in a prospective cohort study. Household sociodemographic information was collected through a baseline questionnaire administered at enrollment. Participants were visited up to six times between July 2015 and February 2016 to collect information on recent childhood acute illness and associated care-seeking behavior. Multivariate logistic regression explored the associations between care-seeking and child, participant, and household characteristics.

RESULTS

We enrolled 743 mothers with 1066 eligible children, completing 2585 follow-up interviews (90% completion). Overall acute illness prevalence in children was 26% with care sought from a health facility during 71% of episodes. Multivariable logistic regression showed care-seeking was associated with the number of reported symptoms (Odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.5-3.9) and household insurance coverage (OR = 2.2, 95% CI = 1.1-4.3). We observed an interaction between the associations of illness severity and maternal employment on care-seeking. Somewhat-to-very severe illness was associated with increased care-seeking among both employed (OR = 5.0, 95% CI = 2.2-11.1) and currently unemployed mothers (OR = 7.0, 95% CI = 3.9-12.6). Maternal employment was associated with reduced care-seeking for non-severe illness (OR = 0.3, 95% CI = 0.1-0.7), but not associated with care-seeking for somewhat-to-very severe illness. Child sex was not associated with care-seeking.

CONCLUSIONS

This study demonstrates the importance of illness characteristics in determining facility-based care-seeking while also suggesting that maternal employment resulted in decreased care-seeking among non-severe illness episodes. The nature of the association between maternal employment and care-seeking is unclear and should be explored through additional studies. Similarly, the absence of male bias in care-seeking should be examined to assess for potential bias at other stages in the management of childhood illness.

Housing and child health in sub-Saharan Africa: A cross-sectional analysis

BACKGROUND

Housing is essential to human well-being but neglected in global health. Today, housing in Africa is rapidly improving alongside economic development, creating an urgent need to understand how these changes can benefit health. We hypothesised that improved housing is associated with better health in children living in sub-Saharan Africa (SSA). We conducted a cross-sectional analysis of housing conditions relative to a range of child health outcomes in SSA.

METHODS AND FINDINGS

Cross-sectional data were analysed for 824,694 children surveyed in 54 Demographic and Health Surveys, 21 Malaria Indicator Surveys, and two AIDS Indicator Surveys conducted in 33 countries between 2001 and 2017 that measured malaria infection by microscopy or rapid diagnostic test (RDT), diarrhoea, acute respiratory infections (ARIs), stunting, wasting, underweight, or anaemia in children aged 0-5 years. The mean age of children was 2.5 years, and 49.7% were female. Housing was categorised into a binary variable based on a United Nations definition comparing improved housing (with improved drinking water, improved sanitation, sufficient living area, and finished building materials) versus unimproved housing (all other houses). Associations between house type and child health outcomes were determined using conditional logistic regression within surveys, adjusting for prespecified covariables including age, sex, household wealth, insecticide-treated bed net use, and vaccination status. Individual survey odds ratios (ORs) were pooled using random-effects meta-analysis. Across surveys, improved housing was associated with 8%-18% lower odds of all outcomes except ARI (malaria infection by microscopy: adjusted OR [aOR] 0.88, 95% confidence intervals [CIs] 0.80-0.97, p = 0.01; malaria infection by RDT: aOR 0.82, 95% CI 0.77-0.88, p < 0.001; diarrhoea: aOR 0.92, 95% CI 0.88-0.97, p = 0.001; ARI: aOR 0.96, 95% CI 0.87-1.07, p = 0.49; stunting: aOR 0.83, 95% CI 0.77-0.88, p < 0.001; wasting: aOR 0.90, 95% CI 0.83-0.99, p = 0.03; underweight: aOR 0.85, 95% CI 0.80-0.90, p < 0.001; any anaemia: aOR 0.87, 95% CI 0.82-0.92, p < 0.001; severe anaemia: aOR 0.89, 95% CI 0.84-0.95, p < 0.001). In comparison, insecticide-treated net use was associated with 16%-17% lower odds of malaria infection (microscopy: aOR 0.83, 95% CI 0.78-0.88, p < 0.001; RDT: aOR 0.84, 95% CI 0.79-0.88, p < 0.001). Drinking water source and sanitation facility alone were not associated with diarrhoea. The main study limitations are the use of self-reported diarrhoea and ARI, as well as potential residual confounding by socioeconomic position, despite adjustments for household wealth and education.

CONCLUSIONS

In this study, we observed that poor housing, which includes inadequate drinking water and sanitation facility, is associated with health outcomes known to increase child mortality in SSA. Improvements to housing may be protective against a number of important childhood infectious diseases as well as poor growth outcomes, with major potential to improve children's health and survival across SSA.

Consumption of a Natural High-Intensity Sweetener Enhances Activity and Expression of Rabbit Intestinal Na+/Glucose Cotransporter 1 (SGLT1) and Improves Colibacillosis-Induced Enteric Disorders

Absorption of glucose, via intestinal Na⁺/glucose cotransporter 1 (SGLT1), activates salt and water absorption and is an effective route for treating Escherichia coli (E. coli)-induced diarrhea. Activity and expression of SGLT1 is regulated by sensing of sugars and artificial/natural sweeteners by the intestinal sweet receptor T1R2-T1R3 expressed in enteroendocrine cells. Diarrhea, caused by the bacterial pathogen E. coli, is the most common post-weaning clinical feature in rabbits, leading to mortality. We demonstrate here that, in rabbits with experimentally E. coli-induced diarrhea, inclusion of a supplement containing stevia leaf extract (SL) in the feed decreases cumulative morbidity, improving clinical signs of disease (p < 0.01). We show that the rabbit intestine expresses T1R2-T1R3. Furthermore, intake of SL enhances activity and expression of SGLT1 and the intestinal capacity to absorb glucose (1.8-fold increase, p < 0.05). Thus, a natural plant extract sweetener can act as an effective feed additive for lessening the negative impact of enteric diseases in animals.

A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol

BACKGROUND

Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention.

METHODS

ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment.

DISCUSSION

Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.

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.

Diarrhoeal disease and subsequent risk of death in infants and children residing in low-income and middle-income countries: analysis of the GEMS case-control study and 12-month GEMS-1A follow-on study

Background

The Global Enteric Multicenter Study (GEMS) was a 3-year case-control study that measured the burden, aetiology, and consequences of moderate-to-severe diarrhoea (MSD) in children aged 0–59 months. GEMS-1A, a 12-month follow-on study, comprised two parallel case-control studies, one assessing MSD and the other less-severe diarrhoea (LSD). In this report, we analyse the risk of death with each diarrhoea type and the specific pathogens associated with fatal outcomes.

Methods

GEMS was a prospective, age-stratified, matched case-control study done at seven sites in Africa and Asia. Children aged 0–59 months with MSD seeking care at sentinel health centres were recruited along with one to three randomly selected matched community control children without diarrhoea. In the 12-month GEMS-1A follow-on study, children with LSD and matched controls, in addition to children with MSD and matched controls, were recruited at six of the seven sites; only cases of MSD and controls were enrolled at the seventh site. We compared risk of death during the period between enrolment and one follow-up household visit done about 60 days later (range 50–90 days) in children with MSD and LSD and in their respective controls. Approximately 50 pathogens were detected using, as appropriate, classic bacteriology, immunoassays, gel-based PCR and reverse transcriptase PCR, and quantitative real-time PCR (qPCR). Specimens from a subset of GEMS cases and controls were also tested by a TaqMan Array Card that compartmentalised probe-based qPCR for 32 enteropathogens.

Findings

223 (2·0%) of 11 108 children with MSD and 43 (0·3%) of 16 369 matched controls died between study enrolment and the follow-up visit at about 60 days (hazard ratio [HR] 8·16, 95% CI 5·69–11·68, p<0·0001). 12 (0·4%) of 2962 children with LSD and seven (0·2%) of 4074 matched controls died during the follow-up period (HR 2·78, 95% CI 0·95–8·11, p=0·061). Risk of death was lower in children with dysenteric MSD than in children with non-dysenteric MSD (HR 0·20, 95% CI 0·05–0·87, p=0·032), and lower in children with LSD than in those with non-dysenteric MSD (HR 0·29, 0·14–0·59, p=0·0006). In children younger than 24 months with MSD, infection with typical enteropathogenic Escherichia coli, enterotoxigenic E coli encoding heat-stable toxin, enteroaggregative E coli, Shigella spp (non-dysentery cases), Aeromonas spp, Cryptosporidium spp, and Entamoeba histolytica increased risk of death. Of 61 deaths in children aged 12–59 months with non-dysenteric MSD, 31 occurred among 942 children qPCR-positive for Shigella spp and 30 deaths occurred in 1384 qPCR-negative children (HR 2·2, 95% CI 1·2–3·9, p=0·0090), showing that Shigella was strongly associated with increased risk of death.

Interpretation

Risk of death is increased following MSD and, to a lesser extent, LSD. Considering there are approximately three times more cases of LSD than MSD in the population, more deaths are expected among children with LSD than in those with MSD. Because the major attributable LSD-associated and MSD-associated pathogens are the same, implementing vaccines and rapid diagnosis and treatment interventions against these major pathogens are rational investments.

Funding

Bill & Melinda Gates Foundation.

Evolution of the World Health Organization's programmatic actions to control diarrheal diseases

The Program for the Control of Diarrheal Diseases (CDD) of the World Health Organization (WHO) was created in 1978, the year the Health for All Strategy was launched at the Alma Ata International Conference on Primary Health Care. CDD quickly became one of the pillars of this strategy, with its primary goal of reducing diarrhea-associated mortality among infants and young children in developing countries. WHO expanded the previous cholera-focused unit into one that addressed all diarrheal diseases, and uniquely combined support to research and to national CDD Programs. We describe the history of the Program, summarize the results of the research it supported, and illustrate the outcome of the Program's control efforts at country and global levels. We then relate the subsequent evolution of the Program to an approach that was more technically broad and programmatically narrow and describe how this affected diarrheal diseases-related activities globally and in countries.

Drivers of the reduction in childhood diarrhea mortality 1980-2015 and interventions to eliminate preventable diarrhea deaths by 2030

BACKGROUND

Childhood diarrhea deaths have declined more than 80% from 1980 to 2015, in spite of an increase in the number of children in low- and middle-income countries (LMIC). Possible drivers of this remarkable accomplishment can guide the further reduction of the half million annual child deaths from diarrhea that still occur.

METHODS

We used the Lives Saved Tool, which models effects on mortality due to changes in coverage of preventive or therapeutic interventions or risk factors, for 50 LMIC to determine the proximal drivers of the diarrhea mortality reduction.

RESULTS

Diarrhea treatment (oral rehydration solution [ORS], zinc, antibiotics for dysentery and management of persistent diarrhea) and use of rotavirus vaccine accounted for 49.7% of the diarrhea mortality reduction from 1980 to 2015. Improvements in nutrition (stunting, wasting, breastfeeding practices, vitamin A) accounted for 38.8% and improvements in water, sanitation and handwashing for 11.5%. The contribution of ORS was greater from 1980 to 2000 (58.0% of the reduction) than from 2000 to 2015 (30.7%); coverage of ORS increased from zero in 1980 to 29.5% in 2000 and more slowly to 44.1% by 2015. To eliminate the remaining childhood diarrhea deaths globally, all these interventions will be needed. Scaling up diarrhea treatment and rotavirus vaccine, to 90% coverage could reduce global child diarrhea mortality by 74.1% from 2015 levels by 2030. Adding improved nutrition could increase that to 89.1%. Finally, adding increased use of improved water sources, sanitation and handwashing could result in a 92.8% reduction from the 2015 level.

CONCLUSIONS

Employing the interventions that have resulted in such a large reduction in diarrhea mortality in the last 35 years can virtually eliminate remaining childhood diarrhea deaths by 2030.

Drivers of the progress achieved by Peru in reducing childhood diarrhoea mortality: a country case study

BACKGROUND

Childhood diarrhoea mortality has declined substantially in Peru in recent decades. We documented trends in childhood diarrhoea mortality from 1980 to 2015, along with trends in coverage of diarrhoea-related interventions and risk factors, to identify the main drivers of mortality reduction.

METHODS

We conducted desk reviews on social determinants, policies and programmes, and diarrhoea-related interventions implemented during the study period. We reviewed different datasets on child mortality, and on coverage of diarrhoea-related interventions. We received input from individuals familiar with implementation of diarrhoea-related policies and programmes. We used the Lives Saved Tool (LiST) to help explain the reasons for the decline in diarrhoea mortality from 1980 to 2015 and to predict additional reduction with further scale up of diarrhoea-related interventions by 2030.

RESULTS

In Peru under-five diarrhoea mortality declined from 23.3 in 1980 to 0.8 per 1000 livebirths in 2015. The percentage of under-five diarrhoea deaths as related to total under-five deaths was reduced from 17.8% in 1980 to 4.9% in 2015. Gross domestic product increased and poverty declined from 1990 to 2015. Access to improved water increased from 56% in 1986 to 79.3% in 2015. Oral rehydrating salts (ORS) use during an episode of diarrhoea increased from 3.6% in 1986 to 32% in 2015. Vertical programmes focused on diarrhoea management with ORS were implemented successfully in the 1980s and 1990s, and were replaced by integrated crosscutting interventions since the early 2000s. LiST analyses showed that about half (53.9%) of the reduction in diarrhoea mortality could be attributed to improved water, sanitation and hygiene, 25.0% to direct diarrhoea interventions and 21.1% to nutrition. The remaining mortality could be reduced by three-quarters by 2030 with improved diarrhoea treatment and further with enhanced breastfeeding practices and reduction in stunting. LiST does not take into account the role of social determinants.

CONCLUSIONS

The reduction of diarrhoeal under-five mortality in Peru can be explained by a combination of factors, including improvement of social determinants, child nutrition, diarrhoea treatment with ORS and prevention with rotavirus vaccine and increased access to water and sanitation. The already low rate of diarrhoea mortality could be further reduced by a number of interventions, especially additional use of ORS and zinc for diarrhoea treatment. Peru is a remarkable example of a country that was able to reduce childhood diarrhoea mortality by implementing interventions through vertical programmes initially, and afterwards through implementation of integrated multisectoral packages targeting prevalent illnesses and multi-causal problems like stunting.

Effect of Early Adverse Events on Survival Outcomes of Patients with Metastatic Colorectal Cancer Treated with Ramucirumab

BACKGROUND

Studies of patients treated with bevacizumab and other vascular epithelial growth factor (VEGF) inhibitors have reported that hypertension adverse events (AEs) are associated with improved overall survival (OS) or progression-free survival (PFS).

OBJECTIVE

Our objective was to evaluate the association between early AEs and survival outcomes for patients treated with ramucirumab, an antibody targeting the VEGF receptor-2 (VEGFR-2), plus FOLFIRI for metastatic colorectal cancer (mCRC).

METHODS

Data from 529 patients treated with ramucirumab plus FOLFIRI for mCRC in the RAISE clinical trial (NCT01183780) were evaluated to see whether early (first 6 weeks of therapy) AEs predicted subsequent OS and PFS. A Cox proportional hazard approach was used to evaluate associations between early AEs and survival outcomes. A secondary analysis between FOLFIRI and placebo was conducted as a sensitivity analysis.

RESULTS

Of 529 patients treated with ramucirumab plus FOLFIRI, 479 were alive and progression free at 6 weeks after commencing therapy. No significant association was identified between hypertension occurring within the first 42 days of ramucirumab plus FOLFIRI therapy and OS (grade 1-2, hazard ratio [HR] 0.90 [95% confidence interval (CI) 0.66-1.24]; grade 3+, HR 1.02 [95% CI 0.67-1.55]; P = 0.803) or PFS (grade 1-2, HR 0.98 [95% CI 0.74-1.28]; grade 3+, HR 0.93 [95% CI 0.64-1.37]; P = 0.93). However, there was a significant association between diarrhea occurring within the first 42 days of ramucirumab plus FOLFIRI therapy and worse OS (grade 1-2, HR 0.96 [95% CI 0.76-1.20]; grade 3+, HR 2.72 [95% CI 1.67-4.44]; P = 0.001) and PFS (grade 1-2, HR 1.01 [95% CI 0.83-1.23]; grade 3+, HR 2.22 [95% CI 1.43-3.45]; P = 0.005). No other AEs were significantly associated with OS or PFS.

CONCLUSIONS

Ramucirumab-induced hypertension was not associated with improved OS and PFS in patients with mCRC treated with ramucirumab and FOLFIRI, but severe diarrhea was associated with poorer OS and PFS.

CLINICAL TRIAL REGISTRATION

No. NCT01183780.

Factors associated with the decline in under-five diarrhea mortality in India: a LiST analysis

BACKGROUND

India has achieved 86% reduction in the number of under-five diarrheal deaths from 1980 to 2015. Nonetheless diarrhea is still among the leading causes of under-five deaths. The aim of this analysis was to study the contribution of factors that led to decline in diarrheal deaths in the country and the effect of scaling up of intervention packages to address the remaining diarrheal deaths.

METHODS

We assessed the attribution of different factors and intervention packages such as direct diarrhea case management interventions, nutritional factors and WASH interventions which contributed to diarrhea specific under-five mortality reduction (DSMR) during 1980 to 2015 using the Lives Saved Tool (LiST). The potential impact of scaling up different packages of interventions to achieve universal coverage levels by year 2030 on reducing the number of remaining diarrheal deaths were estimated.

RESULTS

The major factors associated with DSMR reduction in under-fives during 1980 to 2015, were increase in ORS use, reduction in stunting prevalence, improved sanitation, changes in age appropriate breastfeeding practices, increase in the vitamin-A supplementation and persistent diarrhea treatment. ORS use and reduction in stunting were the two key interventions, each accounting for around 32% of the lives saved during this period. Scaling up the direct diarrhea case management interventions from the current coverage levels in 2015 to achieve universal coverage levels by 2030 can save around 82 000 additional lives. If the universal targets for nutritional factors and WASH interventions can be achieved, an additional 23 675 lives can potentially be saved.

CONCLUSIONS

While it is crucial to improve the coverage and equity in ORS use, an integrated approach to promote nutrition, WASH and direct diarrhea interventions is likely to yield the highest impact on reducing the remaining diarrheal deaths in under-five children.

Bangladesh: a success case in combating childhood diarrhoea

BACKGROUND

Bangladesh had a large reduction in childhood deaths due to diarrhoeal disease in recent decades. This paper explores the preventive, promotive, curative and contextual drivers that helped Bangladesh achieve this exemplary success.

METHODS

Primary and secondary data collection approaches were used to document trends in reduction of Diarrhoea Specific Mortality Rate (DSMR) between 1980 and 2015, understand what policies and programmes played key roles, and estimate the contribution of specific interventions that were implemented during the period. Data acquisition involved relevant document reviews and in-depth interviews with key stake-holders. A systematic search of literature was undertaken to explore socio-economic, aetiological, behavioural, and nutritional drivers of diarrhoeal disease reduction in Bangladesh. Finally, we used LiST (Lives Saved Tool) to model the contributions of the relevant interventions during three time periods (1980-2015, 1980-2000 and 2000-2015), and to project the number of lives saved in 2030 (compared to 2015) if these interventions were implemented at near universal coverage (90%).

RESULTS

The factors which likely had the most impact on DSMR were the coordinated efforts of the Government of Bangladesh (GoB) with non-government organizations (NGOs) and the private sector that enabled swift implementation, at scale, of interventions like oral rehydration solution (ORS) and zinc, promotion of breastfeeding, handwashing and sanitary latrines (WASH), as well as improvements in female education and nutrition. Compared to 1980, we found ORS and reduction in stunting prevalence had the greatest impact on DSMR, saving roughly 70 000 lives combined in 2015. Until 2000, ORS had a higher contribution to DSMR reduction than reduction in stunting prevalence. This proportionate contribution was reversed during 2000-2015. At near universal coverage (90%) of combined direct diarrhoeal disease, nutrition and WASH interventions, we project that an additional 5356 deaths due to diarrhoea could be averted in 2030.

CONCLUSION

Bangladesh's achievement in reduction of DSMR highlights the important role of an enabling policy environment that fostered coordinated efforts of the public and private sectors and NGOs for maximal impact. To maintain this momentum, evidence-based interventions should be scaled up at universal coverage.

Environmental factors affecting childhood diarrheal disease among under-five children in Jamma district, South Wello zone, Northeast Ethiopia

BACKGROUND

Globally, diarrhea is the leading cause of morbidity and mortality among less than 5 years old children and it contributes to the deaths of approximately one million children every year. In Ethiopia, diarrhea is the second cause of under-five mortality and morbidity. However, in the study area, studies were limited. Therefore, this study has assessed the prevalence of diarrhea and associated factors among < 5 years of age in Jamma district, Northeast Ethiopia.

METHODS

A community-based cross-sectional study was conducted from August 15 to September 15, 2017, in Jamma district, South Wello zone, northeast Ethiopia. A Systematic random sampling technique was used to select 614 households and a pretested structured questionnaire was used to collect the data. A multivariable logistic regression analysis was used to investigate factors associated with diarrheal disease. Adjusted Odds Ratio (AOR) with the corresponding 95% Confidence Interval (CI) for variables with P-value < 0.05 was used to show statistically significant association.

RESULTS

In this study, the prevalence of diarrhea among under-five children was 23.1% (95% CI: (19.4, 26.5). Child's age 6 to 23 months [AOR: 2.46, 95% CI: (1.49, 4.05)], Living in rural area [AOR: 2.75, 95% CI: (1.33,5.66)], absence of latrine [AOR: 4.80, 95% CI: (2.39,9.60)], absence of handwashing facility [AOR: 2.45, 95% CI: (1.53,3.93], unprotected drinking water source [AOR:2.68, 95% CI: (1.54,4.68)], and Improper waste disposal practices [AOR:3.86, 95% CI: (2.38,6.26)] were associated with diarrhea disease.

CONCLUSION

There was a high prevalence of diarrheal disease among children in the study area. Child age, rural residence, availability of latrine and handwashing facility, source of drinking water, and improper waste disposal were notably associated with childhood diarrheal disease. Therefore, improving handwashing practices and pure water supply, proper waste disposal including the availability of latrines would minimize the burden of diarrheal disease.

Geospatial analysis of childhood morbidity in Ghana

INTRODUCTION

Childhood morbidities are common in Ghana. The present study sought to geospatially analyze morbidities among children (0-23 months of age) using five different survey datasets (1993-2014) from the Ghana Demographic and Health Survey.

METHODS

Logistic regression was used to examine childhood morbidity within a place of residence. Then three spatial statistical tools were applied to analyze morbidities among children (0-23 months of age). These tools were: spatial autocorrelation (Global Moran's I)-used to examine clustering or dispersion patterns; cluster and outlier analysis (Anselin's local Moran's I)-to ascertain geographic composition of childhood morbidity clusters and outliers; and hot spot analysis (Getis-Ord G)-to identify clusters of high values (hot spots) and low values (cold spots).

RESULTS

Children in rural areas were much burdened with the occurrence of childhood morbidity. The study revealed positive spatial autocorrelation for childhood morbidity in Ghana. Childhood morbidity (diarrhoea, ARI, anaemia, and fever) clusters were identified within districts in the country. Children in rural areas were more likely to be morbid with diarrhoea, anaemia, and fever compared to those in urban areas. Hot spot districts for diarrhoea, anaemia and fever were mainly situated in semi-arid areas and those with ARI were located both at the semi-arid areas and coastal portions of Ghana.

CONCLUSION

Rural children are much exposed to have higher burden of a childhood morbidity compared to their urban counterparts. Most semi-arid districts in Ghana are burdened with diarrhoea, ARI, anaemia, and fever. To minimize the occurrence of childhood morbidity in Ghana, designing of more context-based interventions to target hot spots districts of these morbidities are required in order to use scarce resources judiciously.

Seasonal variation and etiologic inferences of childhood pneumonia and diarrhea mortality in India

Control of pneumonia and diarrhea mortality in India requires understanding of their etiologies. We combined time series analysis of seasonality, climate region, and clinical syndromes from 243,000 verbal autopsies in the nationally representative Million Death Study. Pneumonia mortality at 1 month-14 years was greatest in January (Rate ratio (RR) 1.66, 99% CI 1.51-1.82; versus the April minimum). Higher RRs at 1-11 months suggested respiratory syncytial virus (RSV) etiology. India's humid subtropical region experienced a unique summer pneumonia mortality. Diarrhea mortality peaked in July (RR 1.66, 1.48-1.85) and January (RR 1.37, 1.23-1.48), while deaths with fever and bloody diarrhea (indicating enteroinvasive bacterial etiology) showed little seasonality. Combining mortality at ages 1-59 months with prevalence surveys, we estimate 40,600 pneumonia deaths from Streptococcus pneumoniae, 20,700 from RSV, 12,600 from influenza, and 7200 from Haemophilus influenzae type b and 24,700 diarrheal deaths from rotavirus occurred in 2015. Careful mortality studies can elucidate etiologies and inform vaccine introduction.

Diarrhea, Dehydration, and the Associated Mortality in Children with Complicated Severe Acute Malnutrition: A Prospective Cohort Study in Uganda

OBJECTIVE

To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition.

STUDY DESIGN

A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality.

RESULTS

Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score.

CONCLUSIONS

Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality.

iCCM data quality: an approach to assessing iCCM reporting systems and data quality in 5 African countries

BACKGROUND

Ensuring the quality of health service data is critical for data-driven decision-making. Data quality assessments (DQAs) are used to determine if data are of sufficient quality to support their intended use. However, guidance on how to conduct DQAs specifically for community-based interventions, such as integrated community case management (iCCM) programs, is limited. As part of the World Health Organization's (WHO) Rapid Access Expansion (RAcE) Programme, ICF conducted DQAs in a unique effort to characterize the quality of community health worker-generated data and to use DQA findings to strengthen reporting systems and decision-making.

METHODS

We present our experience implementing assessments using standardized DQA tools in the six RAcE project sites in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria. We describe the process used to create the RAcE DQA tools, adapt the tools to country contexts, and develop the iCCM DQA Toolkit, which enables countries to carry out regular and rapid DQAs. We provide examples of how we used results to generate recommendations.

RESULTS

The DQA tools were customized for each RAcE project to assess the iCCM data reporting system, trace iCCM indicators through this system, and to ensure that DQAs were efficient and generated useful recommendations. This experience led to creation of an iCCM DQA Toolkit comprised of simplified versions of RAcE DQA tools and a guidance document. It includes system assessment questions that elicit actionable responses and a simplified data tracing tool focused on one treatment indicator for each iCCM focus illness: diarrhea, malaria, and pneumonia. The toolkit is intended for use at the national or sub-national level for periodic data quality checks.

CONCLUSIONS

The iCCM DQA Toolkit was designed to be easily tailored to different data reporting system structures because iCCM data reporting tools and data flow vary substantially. The toolkit enables countries to identify points in the reporting system where data quality is compromised and areas of the reporting system that require strengthening, so that countries can make informed adjustments that improve data quality, strengthen reporting systems, and inform decision-making.

Effect of community-based intervention on improving access to treatment for sick under-five children in hard-to-reach communities in Niger State, Nigeria

BACKGROUND

Access to prompt and appropriate treatment is key to survival for children with malaria, pneumonia and diarrhoea. Community-based services are vital to extending care to remote populations. Malaria Consortium supported Niger state Ministry of Health, Nigeria, to introduce and implement an integrated community case management (iCCM) programme for four years in six local government areas (LGAs). The objective was to increase coverage of effective treatment for malaria, pneumonia and diarrhoea among children aged 2-59 months.

METHODS

The programme involved training, equipping, ongoing support and supervision of 1320 community volunteers (CORPs) to provide iCCM services to their communities in all six LGAs. Demand creation activities were also conducted; these included community dialogues, household mobilization, sensitization and mass media campaigns targeted at programme communities. To assess the level of changes in care seeking and treatment, baseline and endline household surveys were conducted in 2014 and 2017 respectively. For both surveys, a 30×30 multi-stage cluster sampling method was used, the sampling frame being RAcE programme communities.

RESULTS

Care-seeking from an appropriate provider increased overall and for each iCCM illness from 78% to 94% for children presenting with fever (P < 0.01), from 72% to 91% for diarrhoea cases (P < 0.01), and from 76% to 89% for cases of cough with difficult or fast breathing (P < 0.05). For diagnosis and treatment, the coverage of fevers tested for malaria increased from 34% to 77% (P < 0.001) and ACT treatments from 57% to 73% (<0.005); 56% of cases of cough or fast breathing who sought care from a CORP, had their respiratory rate counted and 61% with cough or fast breathing received amoxicillin. At endline caregivers sought care from CORPs in their communities for most cases of childhood illnesses (84%) compared to other providers at hospitals (1%) or health centres (9%).This aligns with caregivers' belief that CORPs are trusted providers (94%) who provide quality services (96%).

CONCLUSION

Implementation of iCCM with focused demand creation activities can improve access to quality lifesaving interventions from frontline community providers in Nigeria. This can contribute towards achieving SDGs if iCCM is scaled up to hard-to-reach areas of all states in the country.

Brief Report: Cofactors of Mortality Among Hospitalized HIV-Infected Children Initiating Antiretroviral Therapy in Kenya

OBJECTIVES

Identifying factors associated with mortality among acutely ill HIV-infected children presenting with advanced HIV disease may help clinicians optimize care for those at highest risk of death.

DESIGN

Using data from a randomized controlled trial (NCT02063880), we determined baseline sociodemographic, clinical, and laboratory cofactors of mortality among HIV-infected children in Kenya.

METHODS

We enrolled hospitalized, HIV-infected, antiretroviral therapy-naive children (0-12 years), initiated antiretroviral therapy, and followed up them for 6 months. We used Cox proportional hazards regression to estimate hazard ratios (HRs) for death and 95% confidence intervals (CIs).

RESULTS

Of 181 enrolled children, 39 (22%) died. Common diagnoses at death were pneumonia or suspected pulmonary tuberculosis [23 (59%)] and gastroenteritis [7 (18%)]. Factors associated with mortality in univariate analysis included age <2 years [HR 3.08 (95% CI: 1.50 to 6.33)], orphaned or vulnerable child (OVC) [HR 2.05 (95% CI: 1.09 to 3.84)], weight-for-age Z score <-2 [HR 2.29 (95% CI: 1.05 to 5.00)], diagnosis of pneumonia with hypoxia [HR 5.25 (95% CI: 2.00 to 13.84)], oral thrush [HR 2.17 (95% CI: 1.15 to 4.09)], persistent diarrhea [HR 3.81 (95% CI: 1.89 to 7.69)], and higher log10 HIV-1 viral load [HR 2.16 (95% CI: 1.35 to 3.46)] (all P < 0.05). In multivariable analysis, age <2 years and OVC status remained significantly associated with mortality.

CONCLUSIONS

Young age and OVC status independently predicted mortality. Hypoxic pneumonia, oral thrush, and persistent diarrhea are important clinical features that predict mortality. Strategies to enhance early diagnosis in children and improve hospital management of critically ill HIV-infected children are needed.

Rotavirus vaccine impact assessment surveillance in India: protocol and methods

INTRODUCTION

Rotavirus infection accounts for 39% of under-five diarrhoeal deaths globally and 22% of these deaths occur in India. Introduction of rotavirus vaccine in a national immunisation programme is considered to be the most effective intervention in preventing severe rotavirus disease. In 2016, India introduced an indigenous rotavirus vaccine (Rotavac) into the Universal Immunisation Programme in a phased manner. This paper describes the protocol for surveillance to monitor the performance of rotavirus vaccine following its introduction into the routine childhood immunisation programme.

METHODS

An active surveillance system was established to identify acute gastroenteritis cases among children less than 5 years of age. For all children enrolled at sentinel sites, case reporting forms are completed and a copy of vaccination record and a stool specimen obtained. The forms and specimens are sent to the referral laboratory for data entry, analysis, testing and storage. Data from sentinel sites in states that have introduced rotavirus vaccine into their routine immunisation schedule will be used to determine rotavirus vaccine impact and effectiveness.

ETHICS AND DISSEMINATION

The Institutional Review Board of Christian Medical College, Vellore, and all the site institutional ethics committees approved the project. Results will be disseminated in peer-reviewed journals and with stakeholders of the universal immunisation programme in India.

Trend of intestinal infectious diseases recorded at a tertiary care hospital in India: an ICD-10 analysis

The World Health Organization identifies the leading cause of morbidity and mortality in developing countries as infectious and communicable diseases. Health records coded uniformly using ICD-10 can form an accurate database and conclusions drawn from this are extremely important for understanding the public health situation.The aim of this study is to analyse the trend of intestinal infectious diseases recorded at a tertiary care hospital in India.A retrospective disease index study was conducted on data comprising 5317 cases from 2012 to 2016 for intestinal infectious diseases, analysed with ICD-10.Of these, 5.5% were from the age group 0-5 years; 57.66% were male; and 85% deaths in this cohort (62/73) were due to diarrhoea and gastroenteritis of presumed infectious origin.The findings of this study highlight an urgent need for health education among the population regarding infectious intestinal diseases and to redesign health promotion and preventive strategies for addressing these problems.

Clinical Indicators of Fatal Dengue in Two Endemic Areas of Colombia: A Hospital-Based Case-Control Study

According to the World Health Organization, 98% of fatal dengue cases can be prevented; however, endemic countries such as Colombia have recorded higher case fatality rates during recent epidemics. We aimed to identify the predictors of mortality that allow risk stratification and timely intervention in patients with dengue. We conducted a hospital-based, case-control (1:2) study in two endemic areas of Colombia (2009-2015). Fatal cases were defined as having either 1) positive serological test (IgM or NS1), 2) positive virological test (RT-PCR or viral isolation), or 3) autopsy findings compatible with death from dengue. Controls (matched by state and year) were hospitalized nonfatal patients and had a positive serological or virological dengue test. Exposure data were extracted from medical records by trained staff. We used conditional logistic regression (adjusting for age, gender, disease's duration, and health-care provider) in the context of multiple imputation to estimate exposure to case-control associations. We evaluated 110 cases and 217 controls (mean age: 35.0 versus 18.9; disease's duration pre-admission: 4.9 versus 5.0 days). In multivariable analysis, retro-ocular pain (odds ratios [OR] = 0.23), nausea (OR = 0.29), and diarrhea (OR = 0.19) were less prevalent among fatal than nonfatal cases, whereas increased age (OR = 2.46 per 10 years), respiratory distress (OR = 16.3), impaired consciousness (OR = 15.9), jaundice (OR = 32.2), and increased heart rate (OR = 2.01 per 10 beats per minute) increased the likelihood of death (AUC: 0.97, 95% confidence interval: 0.96, 0.99). These results provide evidence that features of severe dengue are associated with higher mortality, which strengthens the recommendations related to triaging patients in dengue-endemic areas.

A decade of antiretroviral therapy in Uganda: what are the emerging causes of death?

BACKGROUND

The roll out of antiretroviral therapy (ART) in Sub-Saharan Africa led to a decrease in mortality. Few studies have documented the causes of deaths among patients on long term antiretroviral therapy in Sub-Saharan Africa. Our objective was to describe the causes of death among patients on long term ART in Sub-Saharan Africa.

METHODS

We used data from a prospective cohort of ART naïve patients receiving care and treatment at the Infectious Diseases Institute in Kampala, Uganda. Patients were followed up for 10 years. All deaths were recorded and possible causes established using verbal autopsy. Deaths were grouped as HIV-related (ART toxicities, any opportunistic infections (OIs) and HIV-related malignancies) and non-HIV related deaths while some remained unknown. We used Kaplan Meier survival methods to estimate cumulative incidence and rates of mortality for all causes of death.

RESULTS

Of the 559, (386, 69%) were female, median age 36 years (IQR: 21-44), 89% had WHO clinical stages 3 and 4, and median CD4 count at ART initiation was 98 cells/μL (IQR: 21-163). A total of 127 (22.7%) deaths occurred in 10 years. The HIV related causes of death (n = 70) included the following; Tuberculosis 17 (24.3%), Cryptococcal meningitis 10 (15.7%), Kaposi's Sarcoma 7(10%), HIV related toxicity 6 (8.6%), HIV related anemia 5(7.1%), Pneumocystis carinii Pneumonia (PCP) 5 (7.1%), HIV related chronic diarrhea 4 (5.7%), Non-Hodgkin Lymphoma 3 (4.3%), Herpes Zoster 2 (2.8%), other 10 (14.3%). The non-HIV related causes of death (n = 20) included non-communicable diseases (diabetes, hypertension, stroke) 6 (30%), malaria 3 (15%), pregnancy-related death 2 (10%), cervical cancer 2 (10%), trauma 1(5%) and others 6 (30%).

CONCLUSION

Despite the higher rates of deaths from OIs in the early years of ART initiation, we observed an emergence of non-HIV related causes of morbidity and mortality. It is recommended that HIV programs in resource-limited settings start planning for screening and treatment of non-communicable diseases.

Variation in Childhood Diarrheal Morbidity and Mortality in Africa, 2000-2015

BACKGROUND

Diarrheal diseases are the third leading cause of disease and death in children younger than 5 years of age in Africa and were responsible for an estimated 30 million cases of severe diarrhea (95% credible interval, 27 million to 33 million) and 330,000 deaths (95% credible interval, 270,000 to 380,000) in 2015. The development of targeted approaches to address this burden has been hampered by a paucity of comprehensive, fine-scale estimates of diarrhea-related disease and death among and within countries.

METHODS

We produced annual estimates of the prevalence and incidence of diarrhea and diarrhea-related mortality with high geographic detail (5 km2) across Africa from 2000 through 2015. Estimates were created with the use of Bayesian geostatistical techniques and were calibrated to the results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016.

RESULTS

The results revealed geographic inequality with regard to diarrhea risk in Africa. Of the estimated 330,000 childhood deaths that were attributable to diarrhea in 2015, more than 50% occurred in 55 of the 782 first-level administrative subdivisions (e.g., states). In 2015, mortality rates among first-level administrative subdivisions in Nigeria differed by up to a factor of 6. The case fatality rates were highly varied at the national level across Africa, with the highest values observed in Benin, Lesotho, Mali, Nigeria, and Sierra Leone.

CONCLUSIONS

Our findings showed concentrated areas of diarrheal disease and diarrhea-related death in countries that had a consistently high burden as well as in countries that had considerable national-level reductions in diarrhea burden. (Funded by the Bill and Melinda Gates Foundation.).

Impact of monovalent rotavirus vaccine on diarrhoea-associated post-neonatal infant mortality in rural communities in Malawi: a population-based birth cohort study

BACKGROUND

Rotavirus is a major contributor to child mortality. The effect of rotavirus vaccine on diarrhoea mortality has been estimated in middle-income but not low-income settings, where mortality is high and vaccine effectiveness in reducing admissions to hospital is lower. Empirical population-based mortality studies have not been done in any setting. Malawi introduced monovalent rotavirus vaccine (RV1) in October, 2012. We aimed to investigate the impact and effectiveness of the RV1 vaccine in reducing diarrhoea-associated mortality in infants aged 10-51 weeks.

METHODS

In this population-based cohort study, we included infants born between Jan 1, 2012, and June 1, 2015, in Mchinji, Central Malawi and analysed data on those surviving 10 weeks. Individual vaccination status was extracted from caregiver-held records or report at home visits at 4 months and 1 year of age. Survival to 1 year was confirmed at home visit, or cause of death ascertained by verbal autopsy. We assessed impact (1 minus mortality rate ratio following vs before vaccine introduction) using Poisson regression. Among vaccine-eligible infants (born from Sept 17, 2012), we assessed effectiveness (1 minus hazard ratio) using Cox regression.

FINDINGS

Between Jan 1, 2012, and June 1, 2015, we recruited 48 672 livebirths in Mchinji, among whom 38 518 were vaccine-eligible and 37 570 survived to age 10 weeks. Two-dose versus zero-dose effectiveness analysis included 28 141 infants, of whom 101 had diarrhoea-associated death before 1 year of age. Diarrhoea-associated mortality declined by 31% (95% CI 1-52; p=0·04) after RV1 introduction. Effectiveness against diarrhoea-mortality was 34% (95% CI -28 to 66; p=0·22).

INTERPRETATION

RV1 was associated with substantial reduction in diarrhoea-associated deaths among infants in this rural sub-Saharan African setting. These data add considerable weight to evidence showing the impact of rotavirus vaccine programmes.

FUNDING

Wellcome Trust and GlaxoSmithKline Biologicals.

Association of the Paediatric Admission Quality of Care score with mortality in Kenyan hospitals: a validation study

Background

Measuring the quality of hospital admission care is essential to ensure that standards of practice are met and continuously improved to reduce morbidity and mortality associated with the illnesses most responsible for inpatient deaths. The Paediatric Admission Quality of Care (PAQC) score is a tool for measuring adherence to guidelines for children admitted with acute illnesses in a low-income setting. We aimed to explore the external and criterion-related validity of the PAQC score by investigating its association with mortality using data drawn from a diverse sample of Kenyan hospitals.

Methods

We identified children admitted to Kenyan hospitals for treatment of malaria, pneumonia, diarrhoea, or dehydration from datasets from three sources: an observational study, a clinical trial, and a national cross-sectional survey. We extracted variables describing the process of care provided to patients at admission and their eventual outcomes from these data. We applied the PAQC scoring algorithm to the data to obtain a quality-of-care score for each child. We assessed external validity of the PAQC score by its systematic replication in datasets that had not been previously used to investigate properties of the PAQC score. We assessed criterion-related validity by using hierarchical logistic regression to estimate the association between PAQC score and the outcome of mortality, adjusting for other factors thought to be predictive of the outcome or responsible for heterogeneity in quality of care.

Findings

We found 19 065 eligible admissions in the three validation datasets that covered 27 hospitals, of which 12 969 (68%) were complete cases. Greater guideline adherence, corresponding to higher PAQC scores, was associated with a reduction in odds of death across the three datasets, ranging between 9% (odds ratio 0·91, 95% CI 0·84–0·99; p=0·031) and 30% (0·70, 0·63–0·78; p<0·0001) adjusted reduction per unit increase in the PAQC score, with a pooled estimate of 17% (0·83, 0·78–0·89; p<0·0001). These findings were consistent with a multiple imputation analysis that used information from all observations in the combined dataset.

Interpretation

The PAQC score, designed as an index of the technical quality of care for the three commonest causes of admission in children, is also associated with mortality. This finding suggests that it could be a meaningful summary measure of the quality of care for common inpatient conditions and supports a link between process quality and outcome. It might have potential for application in low-income countries with similar disease profiles and in which paediatric practice recommendations are based on WHO guidelines.

Funding

The Wellcome Trust.

Burden of diarrhea in the Eastern Mediterranean Region, 1990-2015: Findings from the Global Burden of Disease 2015 study

OBJECTIVES

Diarrheal diseases (DD) are an important cause of disease burden, especially in children in low-income settings. DD can also impact children's potential livelihood through growth faltering, cognitive impairment, and other sequelae.

METHODS

As part of the Global Burden of Disease study, we estimated DD burden, and the burden attributable to specific risk factors and etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2015. We calculated disability-adjusted life-years (DALYs)-the sum of years of life lost and years lived with disability-for both sexes and all ages.

RESULTS

We estimate that over 103,692 diarrhea deaths occurred in the EMR in 2015 (95% uncertainty interval: 87,018-124,692), and the mortality rate was 16.0 deaths per 100,000 persons (95% UI: 13.4-19.2). The majority of these deaths occurred in children under 5 (63.3%) (65,670 deaths, 95% UI: 53,640-79,486). DALYs per 100,000 ranged from 304 (95% UI 228-400) in Kuwait to 38,900 (95% UI 25,900-54,300) in Somalia.

CONCLUSIONS

Our findings will guide evidence-based health policy decisions for interventions to achieve the ultimate goal of reducing the DD burden.

Determinants of delay in timely treatment seeking for diarrheal diseases among mothers with under-five children in central Ethiopia: A case control study

Background

Delays in seeking timely appropriate care contributes to a large number of deaths from diarrhea in children. This study aimed to identify determinants of delays in seeking timely treatment by mothers/caregivers of under-five children with diarrheal diseases.

Methods

We used an unmatched case-control study from February—March 2017 among 316 children: 158 cases and 158 controls. Cases were mothers/caregivers with under-five children who had signs/symptoms of diarrhea and sought treatment after 24 hours onset of symptom. Controls sought treatment within 24 hours. Field workers collected data using a pre-tested standardized questionnaire. Multivariate logistic regression was conducted to identify determinants of delay in timely diarrhea treatment seeking. Statistical significance was declared by using a p-value<0.05 and 95% of confidence interval (CI) for an adjusted-odds ratio (AOR).

Results

The determinants of delay in timely treatment seeking of mothers/caregivers of under-five children with diarrheal diseases were children <24months (AOR = 1.9,95%CI:1.1–3.4); fail to attend school (AOR = 2.4, 95%CI:1.2–4.6); being female children (AOR = 1.7,95%CI:1.05–2.9); preferring government health facility for the treatment of children with diarrheal diseases (AOR = 2.9, 95%CI, 1.3–6.7); lack of past history taking children to health facility and lack of counseling (AOR = 4.8, 95%CI:2.0–12.1); being in the15-25 years age (AOR = 1.7, 95%CI:1.1–3.0) and taking children to a health facility as a first response to diarrhea (AOR = 0.1, 95%CI:0.01–0.8).

Conclusions

Age of the child, maternal age, and disease related determinants were determinants for seeking timely treatment to diarrheal diseases. Providing skilled based health education and counseling to mothers/caregivers on seeking timely treatment and taking children with diarrheal diseases to a health facility as a first response to diarrhea is a paramount intervention to reduce morbidity and mortality of children.

Veal calf health on the day of arrival at growers in Ohio

Veal calves are at high risk for disease and mortality in early life. Calves face a number of stressors before arriving at the grower, including long transport times, which may contribute to poor health. Our objectives were to 1) estimate the prevalence of poor health outcomes in veal calves on arrival at growers in Ohio; 2) determine risk factors for health outcomes on arrival, including BW and auction site (spread across 5 states in the Northeastern United States); and 3) determine if health outcomes on arrival predict early mortality. A physical examination was conducted on approximately 30 calves (mean of 45.9 kg [SD 3.0]) from 12 cohorts ( = 383 calves). Exams included a blood sample to determine packed cell volume (an estimate of dehydration using a cutoff > 46%) and total protein (an estimate failure of passive transfer using a cutoff < 5.5 g/dL and 6.0 g/dL to account for dehydration). Diarrhea, respiratory disease, depression, navel inflammation, and a skin tent test (a second indicator of dehydration) were also recorded. Mortality within 4 wk of age was collected from farm records. Descriptive statistics were used to describe the prevalence of calves with poor health outcomes on arrival. Generalized linear mixed models were used to identify risk factors for poor health on arrival and assess if poor health increased the incidence risk of mortality. Upon arrival, 6% (95% confidence interval 4.4 to 7.6%) of calves had failure of passive transfer using a cut-off of 5.5 g/dL, and 22.5% (18.1 to 26.8%) had failure of passive transfer using a cut-off of 5.5 g/dL, and 22.5% (18.1 to 26.8%) had failure of passive transfer using a cut-off of 6.0%; 14% (9.1 to 18.8%) had diarrhea, 0.5% (0 to 1.3%) had respiratory disease, 14% (8.5 to 19.3%) were depressed, and 27% (22.7 to 30.7%) had inflamed navels. In addition, 35.1% (23.5 to 46.6%) of calves were dehydrated using a skin tent test, but only 1.3% (0.0 to 2.9%) were dehydrated based on the packed cell volume threshold. Auction site was associated with depression on arrival ( = 0.008) and tended to be associated with skin tent on arrival ( = 0.08). None of the health variables were predictors of early mortality; however, mortality was generally low for all cohorts (4.3%; range 1.7 to 6.8%). These results estimate the prevalence of dehydration, diarrhea, navel inflammation, and depression in veal calves on arrival at growers and demonstrate that some health outcomes are dependent on auction site. We conclude that there are many opportunities to intervene to improve their health and welfare before the calves arrive at the grower.

Paired Phase II Studies of Erlotinib/Bevacizumab for Advanced Bronchioloalveolar Carcinoma or Never Smokers With Advanced Non-Small-cell Lung Cancer: SWOG S0635 and S0636 Trials

BACKGROUND

Before mutation testing of the epidermal growth factor receptor (EGFR) gene was recognized as highly associated with the activity of EGFR tyrosine kinase inhibitors (TKIs), clinically defined patient populations with bronchioloalveolar carcinoma (BAC) and never smokers were identified as likely to benefit from EGFR TKIs. From preclinical and clinical data suggesting potentially improved efficacy with a combination of an EGFR TKI and the antiangiogenic agent bevacizumab, the Southwestern Oncology Group (SWOG) initiated paired phase II trials to evaluate the combination of erlotinib/bevacizumab in patients with advanced BAC (SWOG S0635) or never smokers with advanced lung adenocarcinoma (SWOG S0636).

MATERIALS AND METHODS

Eligible patients with BAC or adenocarcinoma with BAC features (SWOG S0635) or never smokers with advanced lung adenocarcinoma (SWOG S0636) received erlotinib 150 mg/day with bevacizumab 15 mg/kg until progression or prohibitive toxicity. Never smokers with BAC were preferentially enrolled to SWOG S0636. The primary endpoint for both trials was overall survival.

RESULTS

A total of 84 patients were enrolled in the SWOG S0635 trial and 85 in the SWOG S0636 trial. The objective response rate was 22% (3% complete response) in the SWOG S0635 trial and 50% (38% confirmed; 3% complete response) in the SWOG S0636 trial. The median progression-free survival was 5 and 7.4 months in the S0635 and S0636 trials, respectively. The median overall survival was 21 and 29.8 months, respectively. Toxicity consisted mainly of rash and diarrhea in both trials.

CONCLUSION

Although the field has moved toward molecular, rather than clinical, selection of patients as optimal candidates for EGFR TKI therapy, these results support the hypothesis that a subset of patients in whom erlotinib is particularly active could receive an incremental benefit from the addition of bevacizumab.

Long-term follow-up of IPEX syndrome patients after different therapeutic strategies: An international multicenter retrospective study

Background

Immunodysregulation polyendocrinopathy enteropathy x-linked(IPEX) syndromeis a monogenic autoimmune disease caused by FOXP3 mutations. Because it is a rare disease, the natural history and response to treatments, including allogeneic hematopoietic stem cell transplantation (HSCT) and immunosuppression (IS), have not been thoroughly examined.

Objective

This analysis sought to evaluate disease onset, progression, and long-term outcome of the 2 main treatments in long-term IPEX survivors.

Methods

Clinical histories of 96 patients with a genetically proven IPEX syndrome were collected from 38 institutions worldwide and retrospectively analyzed. To investigate possible factors suitable to predict the outcome, an organ involvement (OI) scoring system was developed.

Results

We confirm neonatal onset with enteropathy, type 1 diabetes, and eczema. In addition, we found less common manifestations in delayed onset patients or during disease evolution. There is no correlation between the site of mutation and the disease course or outcome, and the same genotype can present with variable phenotypes. HSCT patients (n = 58) had a median follow-up of 2.7 years (range, 1 week-15 years). Patients receiving chronic IS (n = 34) had a median follow-up of 4 years (range, 2 months-25 years). The overall survival after HSCT was 73.2% (95% CI, 59.4-83.0) and after IS was 65.1% (95% CI, 62.8-95.8). The pretreatment OI score was the only significant predictor of overall survival after transplant (P = .035) but not under IS.

Conclusions

Patients receiving chronic IS were hampered by disease recurrence or complications, impacting long-term disease-free survival. When performed in patients with a low OI score, HSCT resulted in disease resolution with better quality of life, independent of age, donor source, or conditioning regimen.

Public health regulation and mortality: Evidence from early 20th century milk laws

In this paper, I estimate the impact of city-level public health regulations in the market for cow's milk on the mortality of infants and young children between 1900 and 1920. I find that the introduction of city-level dairy farm inspections reduced mortality from Diarrhea & Enteritis for one-year-old children by 1.3 annual deaths per thousand, a 14 percent effect relative to the baseline rate for this cause and a 3 percent effect relative to the baseline rate for all causes for this age group. Back-of-the-envelope calculations reveal that the benefits from these regulations exceeded costs by at least a factor of two.

Risk factors associated with case fatality in 225 diarrhoeic calves: A retrospective study

The aim of this retrospective study was to identify the major risk factors associated with case fatality in diarrhoeic calves undergoing a standard therapeutic protocol. Clinical and laboratory findings were reviewed in 225 Holstein Friesian diarrhoeic calves over a 2 year period. Calves were treated according to a fluid therapy protocol using an oral electrolyte solution or an IV infusion. After therapy, 159 calves were discharged in a healthy state, whereas 66 calves died. Logistic regression analysis showed that serum total protein (STP) concentration (odds ratio, OR, 0.51; 95% confidence interval, CI 0.31-0.84; P<0.01) and the strength of suckle reflex (OR 4.83; CI 1.17-19.88; P<0.05) were the major risk factors associated with case fatality in diarrhoeic calves. These results could help to distinguish between diarrhoeic calves with a good prognosis and those with a major risk of treatment failure.

Estimating global, regional and national rotavirus deaths in children aged <5 years: Current approaches, new analyses and proposed improvements

BACKGROUND

Rotavirus is a leading cause of diarrhoeal mortality in children but there is considerable disagreement about how many deaths occur each year.

METHODS AND FINDINGS

We compared CHERG, GBD and WHO/CDC estimates of age under 5 years (U5) rotavirus deaths at the global, regional and national level using a standard year (2013) and standard list of 186 countries. The global estimates were 157,398 (CHERG), 122,322 (GBD) and 215,757 (WHO/CDC). The three groups used different methods: (i) to select data points for rotavirus-positive proportions; (ii) to extrapolate data points to individual countries; (iii) to account for rotavirus vaccine coverage; (iv) to convert rotavirus-positive proportions to rotavirus attributable fractions; and (v) to calculate uncertainty ranges. We conducted new analyses to inform future estimates. We found that acute watery diarrhoea was associated with 87% (95% CI 83-90%) of U5 diarrhoea hospitalisations based on data from 84 hospital sites in 9 countries, and 65% (95% CI 57-74%) of U5 diarrhoea deaths based on verbal autopsy reports from 9 country sites. We reanalysed data from the Global Enteric Multicenter Study (GEMS) and found 44% (55% in Asia, and 32% in Africa) rotavirus-positivity among U5 acute watery diarrhoea hospitalisations, and 28% rotavirus-positivity among U5 acute watery diarrhoea deaths. 97% (95% CI 95-98%) of the U5 diarrhoea hospitalisations that tested positive for rotavirus were entirely attributable to rotavirus. For all clinical syndromes combined the rotavirus attributable fraction was 34% (95% CI 31-36%). This increased by a factor of 1.08 (95% CI 1.02-1.14) when the GEMS results were reanalysed using a more sensitive molecular test.

CONCLUSIONS

We developed consensus on seven proposals for improving the quality and transparency of future rotavirus mortality estimates.

Treatment outcome of children with persistent Diarrhoea admitted to an Urban Hospital, Dhaka during 2012-2013

BACKGROUND

Despite availability of treatment guidelines, persistent diarrhoea (PD) has been a major contributor of diarrhoeal deaths in low and middle income countries. We evaluated the outcome of children under the age of 5 years who were treated for PD using management algorithm with locally available foods in a diarrhoeal disease hospital in Dhaka.

METHODS

We extracted retrospective data from electronic database for all the under-five children admitted for PD in the Longer Stay Ward and Intensive Care Unit of the Dhaka hospital at icddr,b between 2012 and 2013. Descriptive analysis was done to explore available baseline socio-demographic, nutritional, and co-morbid statuses, pathogens from stool isolates, duration of treatment, use of antibiotics, duration of hospital stay and treatment success rates. We sought to investigate above mentioned descriptive features in addition to associated factors with time to recover from PD using survival analysis with Cox proportional hazard model.

RESULTS

A total number of 426 children with a median age of 7.46 (inter-quartile range IQR; 5.39, 9.43) months were admitted for PD during the study period. Of these, 95% of children were recovered from PD and discharged from the hospital. The median duration of treatment response was 6 (IQR 4, 9) days. The case fatality rate was 1.17%. Multivariate analysis among the children of 6 months or less showed that the rate of recovery from PD was 57% lower in children with severe stunting compared to those without severe stunting (HR 0.43, 95% CI 0.22, 0.88, p < 0.05), 42% lower in children with severe wasting (HR 0.58, 95% CI 0.36, 0.95, p < 0.05), and 81% reduced in children who developed hospital acquired infection (HAI) compared to those without HAI (HR 0.19, 95% CI 0.06, 0.62, p < 0.05). Among the children who were more than 6 months old, age in months (HR 1.05, 95% CI 1.02, 1.09) and female gender (HR 1.41, 95% CI 1.09, 1.84) had better rates of recovery from PD (p < 0.05). Moreover, among children more than 6 months of age, HAI (HR 0.44, 95% CI 0.26, 0.75), and antibiotic use (HR 0.40, 95% CI 0.28, 0.56) were associated with impeded recovery rates from PD (p < 0.05).

CONCLUSION

The treatment guideline for persistent diarrhoea patients followed at icddr,b Dhaka hospital was found to be successful and can be used in other treatment facilities of Bangladesh and other developing countries where any treatment algorithm for PD is unavailable. More emphasis is required to be given for the prevention of hospital acquired infection that may help to limit the use of antibiotic in order to enhance the recovery rate from PD.

Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age

BACKGROUND

Vitamin A deficiency (VAD) is a major public health problem in low- and middle-income countries, affecting 190 million children under five years of age and leading to many adverse health consequences, including death. Based on prior evidence and a previous version of this review, the World Health Organization has continued to recommend vitamin A supplementation for children aged 6 to 59 months. There are new data available from recently published randomised trials since the previous publication of this review in 2010, and this update incorporates this information and reviews the evidence.

OBJECTIVES

To assess the effects of vitamin A supplementation (VAS) for preventing morbidity and mortality in children aged six months to five years.

SEARCH METHODS

In March 2016 we searched CENTRAL, Ovid MEDLINE, Embase, six other databases, and two trials registers. We also checked reference lists and contacted relevant organisations and researchers to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-RCTs evaluating the effect of synthetic VAS in children aged six months to five years living in the community. We excluded studies involving children in hospital and children with disease or infection. We also excluded studies evaluating the effects of food fortification, consumption of vitamin A rich foods, or beta-carotene supplementation.

DATA COLLECTION AND ANALYSIS

For this update, two reviewers independently assessed studies for inclusion and abstracted data, resolving discrepancies by discussion. We performed meta-analyses for outcomes, including all-cause and cause-specific mortality, disease, vision, and side effects. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

We identified 47 studies (4 of which are new to this review), involving approximately 1,223,856 children. Studies took place in 19 countries: 30 (63%) in Asia, 16 of these in India; 8 (17%) in Africa; 7 (15%) in Latin America, and 2 (4%) in Australia. About one-third of the studies were in urban/periurban settings, and half were in rural settings; the remaining studies did not clearly report settings. Most of the studies included equal numbers of girls and boys and lasted about a year. The included studies were at variable overall risk of bias; however, evidence for the primary outcome was at low risk of bias. A meta-analysis for all-cause mortality included 19 trials (1,202,382 children). At longest follow-up, there was a 12% observed reduction in the risk of all-cause mortality for vitamin A compared with control using a fixed-effect model (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.83 to 0.93; high-quality evidence). This result was sensitive to choice of model, and a random-effects meta-analysis showed a different summary estimate (24% reduction: RR 0.76, 95% CI 0.66 to 0.88); however, the confidence intervals overlapped with that of the fixed-effect model. Nine trials reported mortality due to diarrhoea and showed a 12% overall reduction for VAS (RR 0.88, 95% CI 0.79 to 0.98; 1,098,538 participants; high-quality evidence). There was no significant effect for VAS on mortality due to measles, respiratory disease, and meningitis. VAS reduced incidence of diarrhoea (RR 0.85, 95% CI 0.82 to 0.87; 15 studies; 77,946 participants; low-quality evidence) and measles (RR 0.50, 95% CI 0.37 to 0.67; 6 studies; 19,566 participants; moderate-quality evidence). However, there was no significant effect on incidence of respiratory disease or hospitalisations due to diarrhoea or pneumonia. There was an increased risk of vomiting within the first 48 hours of VAS (RR 1.97, 95% CI 1.44 to 2.69; 4 studies; 10,541 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

Vitamin A supplementation is associated with a clinically meaningful reduction in morbidity and mortality in children. Therefore, we suggest maintaining the policy of universal supplementation for children under five years of age in populations at risk of VAD. Further placebo-controlled trials of VAS in children between six months and five years of age would not change the conclusions of this review, although studies that compare different doses and delivery mechanisms are needed. In populations with documented vitamin A deficiency, it would be unethical to conduct placebo-controlled trials.