Effects of probiotic and synbiotic supplementation on ponderal and linear growth in severely malnourished young infants in a randomized clinical trial

Severe acute malnutrition (SAM) is a major global public health problem. We aimed to assess the effects of probiotic and synbiotic supplementation on rate of weight gain and change in length in young SAM infants. This study was substudy of a single-blind randomized clinical trial (NCT0366657). During nutritional rehabilitation, 67 <6 months old SAM infants were enrolled and randomized to receive either probiotic (Bifidobacterium. infantis EVC001) or synbiotic (B. infantis EVC001 + Lacto-N-neotetraose [LNnT]) or placebo (Lactose) for four weeks and were followed for four more weeks after supplementation. In multivariable linear regression model, the mean rate of weight gain in the probiotic arm compared to placebo was higher by 2.03 unit (P < 0.001), and 1.13 unit (P = 0.030) in the synbiotic arm. In linear mixed-effects model, mean WAZ was higher by 0.57 unit (P = 0.018) in probiotic arm compared to placebo. Although not statistically significant, delta length for age z score (LAZ) trended to be higher among children in probiotc (β = 0.25) and synbiotic (β = 0.26) arms compared to placebo in multivariable linear regression model. Our study describes that young SAM infants had a higher rate of weight gain when supplemented with probiotic alone, compared to their counterparts with either synbiotic or placebo.

Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial

BACKGROUND

Acute diarrhoeal disease management often requires rehydration alone without antibiotics. However, non-indicated antibiotics are frequently ordered and this is an important driver of antimicrobial resistance. The mHealth Diarrhoea Management (mHDM) trial aimed to establish whether electronic decision support improves rehydration and antibiotic guideline adherence in resource-limited settings.

METHODS

A cluster randomised controlled trial was done at ten district hospitals in Bangladesh. Inclusion criteria were patients aged 2 months or older with uncomplicated acute diarrhoea. Admission orders were observed without intervention in the pre-intervention period, followed by randomisation to electronic (rehydration calculator) or paper formatted WHO guidelines for the intervention period. The primary outcome was rate of intravenous fluid ordered as a binary variable. Generalised linear mixed-effect models, accounting for hospital clustering, served as the analytical framework; the analysis was intention to treat. The trial is registered with ClinicalTrials.gov (NCT03154229) and is completed.

FINDINGS

From March 11 to Sept 10, 2018, 4975 patients (75·6%) of 6577 screened patients were enrolled. The intervention effect for the primary outcome showed no significant differences in rates of intravenous fluids ordered as a function of decision-support type. Intravenous fluid orders decreased by 0·9 percentage points for paper electronic decision support and 4·2 percentage points for electronic decision support, with a 4·2-point difference between decision-support types in the intervention period (paper 98·7% [95% CI 91·8-99·8] vs electronic 94·5% [72·2-99·1]; p_interaction=0·31). Adverse events such as complications and mortality events were uncommon and could not be statistically estimated.

INTERPRETATION

Although intravenous fluid orders did not change, electronic decision support was associated with increases in the volume of intravenous fluid ordered and decreases in antibiotics ordered, which are consistent with WHO guidelines.

FUNDING

US National Institutes of Health.

Metagenome analysis of Russian and Georgian Pyophage cocktails and a placebo-controlled safety trial of single phage versus phage cocktail in healthy Staphylococcus aureus carriers

Bacteriophage therapy is a commonly used treatment for Staphylococcus aureus infections in countries of the former Soviet Union, using both single phages and phage cocktails. The scarce data available on Eastern phage cocktails prompted an investigation into commercially-available Pyophage cocktails from two different manufacturers used to treat skin and wound infections. Comparison of the metagenomic composition of two Pyophage products from Georgia and Russia revealed substantial differences in phage-types targeting Escherichia, Enterococcus, Salmonella, Pseudomonas aeruginosa and Proteus, therefore indicating multiple strategies for composing phage cocktails against these bacterial pathogens. Closely-related Kayvirus-like Myoviruses were, however, a shared component against S. aureus within all products, except for the inclusion of a secondary S. aureus Podovirus in one Microgen cocktail. Metagenomic analysis also revealed the presence of several probable prophage sequences but detected no genetic safety risks in terms of virulence factors or antibiotic resistance genes. The safety of broad-spectrum cocktails was tested by comparing the effects of nasal and oral exposure to Eliava Pyophage, a monospecies counterpart and placebo in healthy human carriers of S. aureus. The lack of adverse effects in any treatment groups supports the clinical safety of S. aureus phages administered as a single phage or as phage cocktail.

Bangladeshi children with acute diarrhoea show faecal microbiomes with increased Streptococcus abundance, irrespective of diarrhoea aetiology

We report streptococcal dysbiosis in acute diarrhoea irrespective of aetiology. Compared with 20 healthy local controls, 71 Bangladeshi children hospitalized with acute diarrhoea (AD) of viral, mixed viral/bacterial, bacterial and unknown aetiology showed a significantly decreased bacterial diversity with loss of pathways characteristic for the healthy distal colon microbiome (mannan degradation, methylerythritol phosphate and thiamin biosynthesis), an increased proportion of faecal streptococci belonging to the Streptococcus bovis and Streptococcus salivarius species complexes, and an increased level of E. coli-associated virulence genes. No enteropathogens could be attributed to a subgroup of patients. Elevated lytic coliphage DNA was detected in 2 out of 5 investigated enteroaggregative E. coli (EAEC)-infected patients. Streptococcal outgrowth in AD is discussed as a potential nutrient-driven consequence of glucose provided with oral rehydration solution.

Transferring knowledge into practice: a multi-modal, multi-centre intervention for enhancing nurses' infection control competency in Bangladesh

BACKGROUND

Nurses are considered as the key to infection prevention as they play a major role in treatment as well as taking care of patients.

AIM

To assess the role of a multi-modal intervention (MMI) in improving nurses' competency and adherence to standard infection control practices in Bangladesh.

METHODS

The study adopted a pretest-post-test intervention approach, in three different periods (from 2012 to 2017) in five hospitals (two public, two private, and one autonomous) in Bangladesh. Each study period was divided into three phases: pretest, MMI, and post-test. Data were collected on 642 nurses using direct observation method through a structured checklist.

FINDINGS

After implementing the MMI, overall hand hygiene compliance significantly increased before patient contact (from 1.3% to 50.2%; P < 0.000) and after patient contact (from 2.8% to 59.6%; P < 0.000). Remarkable improvements were also achieved in adherence to use of gloves (from 14.6% to 57.6%; P < 0.000), maintaining sterility of equipment during aseptic techniques (from 34.9% to 86%; P < 0.000), biomedical waste segregation (from 1.8% to 81.3%; P < 0.000) and labelling of procedural sites (from 0% to 85.7%; P < 0.000). Moreover, needlestick injury rate notably decreased (from 6.2% to 0.6%; P < 0.000).

CONCLUSION

MMI can play a vital role in improving nurses' compliance with the standard infection control practices. Such context-specific interventions, which are crucial for preventing healthcare-associated infections and for decreasing occupational hazards, should be replicated in resource-poor countries for achieving universal health coverage by 2030.

When is Helicobacter pylori acquired in populations in developing countries? A birth-cohort study in Bangladeshi children

Helicobacter pylori colonization is prevalent throughout the world, and is predominantly acquired during childhood. In developing countries, >70% of adult populations are colonized with H. pylori and >50% of children become colonized before the age of 10 years. However, the exact timing of acquisition is unknown. We assessed detection of H. pylori acquisition among a birth cohort of 105 children in Mirzapur, Bangladesh. Blood samples collected at time 0 (cord blood), and at 6, 12, 18, and 24 months of life were examined for the presence of IgG and IgA antibodies to whole cell H. pylori antigen and for IgG antibodies to the CagA antigen using specific ELISAs and immunoblotting. Breast milk samples were analyzed for H. pylori-specific IgA antibodies. Cord blood was used to establish maternal colonization status. H. pylori seroprevalence in the mothers was 92.8%. At the end of the two-year follow-up period, 50 (47.6%) of the 105 children were positive for H. pylori in more than one assay. Among the colonized children, CagA prevalence was 78.0%. A total of 58 children seroconverted: 50 children showed persistent colonization and 8 (7.6%) children showed transient seroconversion, but immunoblot analysis suggested that the transient seroconversion observed by ELISA may represent falsely positive results. Acquisition of H. pylori was not influenced by the mother H. pylori status in serum or breastmilk. In this population with high H. pylori prevalence, we confirmed that H. pylori in developing countries is detectable mainly after the first year of life.

Ready-to-Use Therapeutic Food Made From Locally Available Food Ingredients Is Well Accepted by Children Having Severe Acute Malnutrition in Bangladesh

BACKGROUND

With a prevalence of 3.1%, approximately, 450 000 children in Bangladesh are having severe acute malnutrition (SAM). There is currently no national community-based program run by government to take care of these children, one of the reasons being lack of access to ready-to-use therapeutic food (RUTF).

OBJECTIVE

To develop RUTF using locally available food ingredients and test its acceptability.

METHODS

A checklist was prepared for all food ingredients available and commonly consumed in Bangladesh that have the potential of being used for developing a RUTF. Linear programming was used to identify the combinations of nutrients that would result in an ideal RUTF. To test the acceptability of 2 local RUTFs compared to the prototype RUTF, Plumpy'Nut, a clinical trial with a crossover design was conducted among 30 children in the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. The acceptability was determined by using the mean proportion of offered food consumed by the children themselves.

RESULTS

Two RUTFs were developed, one based on chickpea and the other on rice-lentils. The total energy content of 100 g of chickpea and rice-lentil-based RUTF were 537.4 and 534.5 kcal, protein 12.9 and 13.5 g, and fat 31.8 and 31.1 g, respectively, without any significant difference among the group. On an average, 85.7% of the offered RUTF amount was consumed by the children in 3 different RUTF groups which implies that all types of RUTF were well accepted by the children.

CONCLUSION

Ready-to-use therapeutic foods were developed using locally available food ingredients-rice, lentil, and chickpeas. Chickpea-based and rice-lentil-based RUTF were well accepted by children with SAM.

Persistent diarrhea: a persistent infection with enteropathogens or a gut commensal dysbiosis?

In children from developing countries 5-10% of acute diarrhea (AD) episodes develop into persistent diarrhea (PD) defined by > 14 days of diarrhea duration. PD represents a major health burden leading to growth faltering. It is also associated with half of all diarrhea mortality. A rational intervention is thus crucial, but depends on an understanding of the pathogenesis of PD, which is still lacking. Many surveys were conducted in Latin America and in South Asia; they differ, however, with respect to enteropathogens associated with PD. Enteroaggregative strains of Escherichia coli (EAEC) were identified by several studies, but they may reflect selection by the frequent antibiotic use during the preceding AD episode. Epidemiologists have in fact identified antibiotic misuse as a major risk factor for PD. Together with the effectiveness of empirical treatment based on nutritional interventions with lactose-reduced and lactose-free diets and particularly complex plant polysaccharides from green banana, one might suspect a role of commensal gut microbiota dysbiosis instead of a persistent infection with enteropathogens in many PD cases. An analysis of the commensal gut microbiota development in persistent diarrhea during nutritional interventions is likely to increase our understanding of PD pathogenesis.

Hunger and microbiology: is a low gastric acid-induced bacterial overgrowth in the small intestine a contributor to malnutrition in developing countries?

Underproduction of hydrochloric acid into the stomach is frequently encountered in subjects from developing countries. We explore the hypothesis that hypochlorhydria compromises the gastric barrier and favours bacterial overgrowth in the proximal parts of the small intestine where nutrient absorption takes place. Food calories are thus deviated into bacterial metabolism. In addition to an adequate caloric supply, correcting hypochlorhydria might be needed to decrease childhood malnutrition.

From bench to bed and back again: phage therapy of childhood Escherichia coli diarrhea

Over the last 20 years, the Nestlé Research Center in Switzerland and the International Center for Diarrhoeal Diseases Research in Bangladesh have explored the efficacy of alternative biological agents for the treatment of diarrheal diseases. This paper reviews the work of this collaborative effort, particularly on Escherichia coli phage therapy (PT), and discusses the development of the project, starting with the isolation of T4-like coliphages from the stool of diarrhea patients, their pilot plant amplification and purification, and the constitution and testing of a cocktail of T4-like phages in mice. A series of phase I clinical trials has demonstrated the safety of PT. Oral phage given without protection survived gastric passage and was recovered in the feces. Oral T4 phage cocktail was then tested in parallel to a commercial phage product in a phase II randomized, placebo-controlled single-center trial in Bangladeshi children hospitalized with acute E. coli diarrhea. It was found that oral phage did not perform better than the current standard of care by oral rehydration/zinc treatment. Furthermore, fecal E. coli pathogen titers were low and mixed infections were found to be frequent. Microbiota analysis showed a correlation between diarrhea and increased levels of Streptococcus, which raises fundamental questions on the causative agent of diarrhea that may explain PT clinical failure.

The Prevalence of Mixed Helicobacter pylori Infections in Symptomatic and Asymptomatic Subjects in Dhaka, Bangladesh

BACKGROUND

Helicobacter pylori is a highly genetically diverse bacterial species, which can persist in the gastric environment for decades. Recent studies have shown that single infections predominate in developed countries, whereas mixed infections are more prevalent in developing countries. Mixed infections of this bacterium may be important for adaptation to the hostile gastric environment and may facilitate dyspeptic symptoms.

MATERIALS AND METHODS

To calculate the prevalence of mixed infections in symptomatic and asymptomatic subjects, 2010 H. pylori isolates collected from 83 symptomatic and 91 asymptomatic subjects from Dhaka, Bangladesh, were analyzed by (i) random amplified polymorphic DNA fingerprinting (RAPD) and (ii) multiplex PCR amplification for cagA and vacA virulence gene alleles.

RESULTS

The overall prevalence of mixed H. pylori infection was 60.15% (77/128), indicating substantial co-colonization in this population. We additionally found that symptomatic subjects (53%) had a significantly higher rate of mixed infection than asymptomatic individuals (36.3%) (p = .016) and that the prevalence of the cagA and vacA and vacA m1/s1 and vacA m2/s1 alleles were higher in subjects with mixed infection.

CONCLUSION

Our findings suggest that an increased diversity of the H. pylori strains in the gastric environment may contribute to the development of disease symptoms.

Coverage of diarrhoea-associated Escherichia coli isolates from different origins with two types of phage cocktails

Eighty-nine T4-like phages from our phage collection were tested against four collections of childhood diarrhoea-associated Escherichia coli isolates representing different geographical origins (Mexico versus Bangladesh), serotypes (69 O, 27 H serotypes), pathotypes (ETEC, EPEC, EIEC, EAEC, VTEC, Shigella), epidemiological settings (community and hospitalized diarrhoea) and years of isolation. With a cocktail consisting of 3 to 14 T4-like phages, we achieved 54% to 69% coverage against predominantly EPEC isolates from Mexico, 30% to 53% against mostly ETEC isolates from a prospective survey in Bangladesh, 24% to 61% against a mixture of pathotypes isolated from hospitalized children in Bangladesh, and 60% coverage against Shigella isolates. In comparison a commercial Russian phage cocktail containing a complex mixture of many different genera of coliphages showed 19%, 33%, 50% and 90% coverage, respectively, against the four above-mentioned collections. Few O serotype-specific phages and no broad-host range phages were detected in our T4-like phage collection. Interference phenomena between the phage isolates were observed when constituting larger phage cocktails. Since the coverage of a given T4-like phage cocktail differed with geographical area and epidemiological setting, a phage composition adapted to a local situation is needed for phage therapy approaches against E. coli pathogens.

A young male with familial hypercholesterolemia

A nine-year-old Bangladeshi male with a body mass index 16.5 kg/m(2) presented with progressive tuberous xanthomata on both auricles, elbows, gluteal regions and legs since birth. His father, paternal and maternal grandfather had xanthelasma, however, the siblings had none. Examination of the cardiovascular system was otherwise normal. Laboratory investigations were performed on several occasions since he was 4 years of age and revealed extreme dyslipidaemia with very high total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), apolipoprotein B (Apo-B) and lipoprotein(a), and low apolipoprotein-A (Apo-A) levels. Repeated combination of lipid lowering agents with cholestyramine, atorvastatin and ezetimibe were virtually ineffective in improving the lipid profiles. Supplementation therapy with niacin also had no effect. In view of the unavailability in Bangladesh of lipid apheresis, the cornerstone of therapy, the management of the case becomes complicated.

Anti-rotavirus protein reduces stool output in infants with diarrhea: a randomized placebo-controlled trial

BACKGROUND & AIMS

Rotavirus infection is a leading cause of morbidity and mortality in children younger than 5 years of age. Current treatment options are limited. We assessed the efficacy of a llama-derived, heavy-chain antibody fragment called anti-rotavirus protein (ARP1), in modifying the severity and duration of diarrhea in male infants with rotavirus infection.

METHODS

We performed a double-blind, placebo-controlled trial of 176 male infants (6-24 months old) with severe rotavirus-associated diarrhea at Dhaka Hospital, Bangladesh. The infants were randomly assigned to groups given oral ARP1 (15-30 mg/kg/day, n = 88) or placebo (maltodextrin, n = 88) for a maximum of 5 days. The primary outcomes were severity (stool output) and duration of diarrhea and fecal excretion of rotavirus. Secondary outcomes were intake of oral rehydration salt solution, severity of vomiting, and serum levels of rotavirus-specific IgA.

RESULTS

In infants with only rotavirus infection, total cumulative stool output was 305.47 g/kg body weight among those given placebo (n = 63) and 237.03 g/kg body weight among those given ARP1 (n = 61) (a difference of 68.44 g/kg body weight or 22.5%; 95% confidence interval: 18.27-118.59 g/kg body weight; P =.0079). There was a significant reduction in rate of stool output (g/kg/d) in the ARP1 group compared with the placebo group (61%; P = .002). ARP1 had no significant effect in infants with concomitant infections or on any other measured outcomes. No adverse events could be linked to ARP1.

CONCLUSIONS

In a placebo-controlled trial, ARP1 reduced stool output in male infants with severe rotavirus-associated diarrhea. Clinicaltrials.gov number: NCT01259765.

Influence of Helicobacter pylori infection on gastric acid secretion in pre-school Bangladeshi children

BACKGROUND

The effect of Helicobacter pylori (H. pylori) infection on gastric acid secretion (GAS) is poorly defined in children.

OBJECTIVE

To determine whether H. pylori infection is associated with abnormal GAS in children.

METHODS

We studied 30 H. pylori-infected children (identified by a positive urea breath test) and 30 noninfected children of both sexes, aged 2-5 years. Gastric pH and GAS were measured before and 8 weeks after the completion of a 2-week course of anti- H. pylori therapy (omeprazole, clarithromycin, and amoxicillin). Gastric acid output (GAO) was quantified during a 1-h basal period (GAO-B) (mmol/h) and a 1-hour stimulated period (GAO-S) (mmol/hour) following subcutaneous administration of pentagastrin (6 μg/kg).

RESULTS

A significantly greater number of infected children had a high gastric pH (>4.0, p = 0.03) compared with the noninfected group. GAO-B and GAO-S in H. pylori-infected children were significantly lower, around 50%, compared with children without H. pylori infection. H. pylori-eradication therapy resulted in a rise of both the mean GAO-B (paired t-test before vs. after therapy; 0.28 ± 0.40 vs. 0.62 ± 1.0, p = 0.12) and GAO-S (before vs. after therapy; 2.0 ± 1.4 vs. 3.4 ± 2.5, p = 0.001), with values reaching equivalence to those in the H. pylori-negative children (0.71 ± 0.56 for BAO, 3.3 ± 2.0 for SAO, p = NS).

CONCLUSION

The results suggest that the gastric barrier is compromised in children with H. pylori infection in Bangladesh. Improvement of GAO following anti- H. pylori therapy suggests a causal link between H. pylori infection and depressed GAO in this population.

Efficacy of partially hydrolyzed guar gum-added oral rehydration solution in the treatment of severe cholera in adults

BACKGROUND

Partially hydrolyzed guar gum (PHGG) is a water-soluble fiber if added to oral rehydration solution (ORS) and undergoes fermentation in the colon liberating short chain fatty acids (SCFAs). SCFAs potentiate the effect of ORS, reducing the severity of diarrhea.

AIM

To examine the effect of PHGG-added ORS in reducing the stool output and duration of diarrhea in adult cholera.

METHODS

195 male patients were studied in a randomized controlled trial: (a) 65 received ORS + 25 g PHGG; (b) 65 received ORS + 50 g PHGG, and (c) 65 received ORS alone (control). Major outcomes were stool weight and duration of diarrhea.

RESULTS

No significant differences were found in mean +/- SD stool weight (g/kg b.w.) during the first and second 24 h. In the subgroup analysis (excluding very high purging patients, stool weight in the first 24 h was >10 kg), the stool weight (g/kg b.w.) was significantly reduced in the first 24 h in both groups receiving PHGG (PHGG 25 g, 136 +/- 68 vs. PHGG 50 g, 144 +/- 49 vs. control, 176 +/- 43, p = 0.01).

CONCLUSION

PHGG-added ORS might have a beneficial effect in moderately purging adult cholera. However, further studies are warranted to confirm the preliminary findings.

Evidence of intra-familial transmission of Helicobacter pylori by PCR-based RAPD fingerprinting in Bangladesh

Helicobacter pylori is a genetically diverse bacterial species, which has facilitated adaptation to new hosts and persists worldwide. The main objective of this study was to explore intra-familial transmission of H. pylori in Bangladesh. We characterized H. pylori in 35 families including 138 family members using random amplified polymorphic DNA (RAPD) fingerprinting. Forty-six percent of H. pylori isolated from the mother shared a related genotype with strains isolated from their children. Twenty-nine percent of H. pylori isolates of the mother are related to the youngest children. Only 6% of the parents shared related genotype of H. pylori. These findings suggest that mother-to-child transmission occurs in early childhood and is the most probable route of transmission of H. pylori in Bangladesh.

Causal relationship of Helicobacter pylori with iron-deficiency anemia or failure of iron supplementation in children

BACKGROUND & AIMS

We investigated Helicobacter pylori (H pylori)-infection as a cause of iron deficiency (ID) and iron-deficiency anemia (IDA) or treatment failure of iron supplementation.

METHODS

We randomized 200 Hp-infected children (positive urea breath test) 2-5 years of age with IDA (hemoglobin level <110 g/L; serum ferritin level <12 microg/L; and soluble transferrin receptor >8.3 mg/L) or ID (serum ferritin level <12 microg/L or soluble transferrin receptor level >8.3 mg/L) to 1 of 4 regimens: 2-week anti-Hp therapy (amoxicillin, clarithromycin, and omeprazole) plus 90-day oral ferrous sulfate (anti-Hp plus iron), 2-week anti-Hp therapy alone, 90-day oral iron alone, or placebo. Sixty noninfected children with IDA received iron treatment as negative control.

RESULTS

Hp-infected children receiving iron had significantly less frequent treatment failure compared with those with no iron in correcting IDA (11% [95% confidence interval (CI), 2%-20%] for anti-Hp plus iron, 0% for iron alone vs 33% [95% CI, 26%-46%] for anti-Hp and 45% [95% CI, 31%-59%] for placebo; chi(2) = 127; P < .0001), ID (19% [95% CI, 8%-30%] for anti-Hp plus iron, 7% [95% CI, 0%-14%] for iron alone vs 65% [95% CI, 52%-78%] for anti-Hp alone, and 78% [95% CI, 66%-90%] for placebo; chi(2) = 124; P < .0001), or anemia (34% [95% CI, 20%-40%] for anti-Hp plus iron, 27% [95% CI, 14%-40%] for iron alone vs 65% [95% CI, 52%-78%] for anti-Hp alone and 78% [95% CI, 66%-90%] for placebo; chi(2) = 46; P < .0001). Cure rates of IDA, ID, or anemia with iron were comparable with that of the negative control group. Improvements in iron status also were significantly greater in groups with iron.

CONCLUSIONS

H pylori is neither a cause of IDA/ID nor a reason for treatment failure of iron supplementation in young Bangladeshi children.

Successful treatment of rotavirus-induced diarrhoea in suckling mice with egg yolk immunoglobulin

The role of specific immunoglobulins at mucosal sites in imparting protection against disease, such as rotavirus-associated diarrhoea, is well-established. Oral immunoglobulin therapy with egg yolk-derived anti-rotavirus immunoglobulins has previously been shown to achieve moderate therapeutic effect in diarrhoea due to rotavirus in a clinical trial. Here, data on the therapeutic potential of the same immunoglobulin preparation in an infant mouse model of rotavirus-induced diarrhoea is presented. The use of an animal model has allowed therapy to be evaluated with higher doses of immunoglobulins and has suggested that an improved therapeutic effect can be achieved by increasing the dose in the clinical setting.

Reduction in morbidity of rotavirus induced diarrhoea in mice by yeast produced monovalent llama-derived antibody fragments

Apart from the use of oral rehydration solution, there are currently no treatment modalities for rotavirus induced diarrhoea, which is particularly relevant to developing countries. Fragments derived from llama heavy chain antibodies were previously shown to be highly stable, efficiently produced in yeast and exhibiting high epitope specific affinity. We now aim to demonstrate that these antibody fragments are capable of reducing morbidity of rotavirus induced diarrhoea. Here we show the isolation of rotavirus specific antibody fragments and their capability of reducing the morbidity of rotavirus induced diarrhoea in vivo in mice. They could provide a treatment modality for the moderation of human rotavirus infections having a significant impact on the course of an often fatal childhood disease.

Lactobacillus paracasei strain ST11 has no effect on rotavirus but ameliorates the outcome of nonrotavirus diarrhea in children from Bangladesh

BACKGROUND

Previous studies have shown that selected strains of lactobacilli that are administered orally result in a modest reduction of diarrhea duration. However, duration alone is not considered optimal for therapeutic evaluation of any agent in diarrhea.

OBJECTIVE

To examine the effect of a new probiotic, Lactobacillus paracasei strain ST11 (ST11), in acute childhood diarrhea by using evaluation criteria recommended by the World Health Organization.

METHODS

In a randomized, double-blind, placebo-controlled clinical trial, 230 male infants and young children, 4 to 24 months of age, presenting with diarrhea of <2 days' duration were admitted to the metabolic research ward of the International Centre for Diarrheal Disease Research, Bangladesh, and fed 10(10) colony-forming units of lyophilized ST11 or placebo daily for 5 days. Stool output and frequency, oral rehydration solution intake, and excretion of rotavirus were monitored daily.

RESULTS

No effect of ST11 treatment on severe rotavirus diarrhea was observed. However, the probiotic treatment did significantly reduce cumulative stool output (225 +/- 218 vs 381 +/- 240 mL/kg), stool frequency (27.9 +/- 17 vs 42.5 +/- 26), and oral rehydration solution intake (180 +/- 207 vs 331 +/- 236 mL/kg) in children with less-severe nonrotavirus diarrhea compared with those receiving placebo treatment. A significantly higher proportion of nonrotavirus children receiving ST11 had their diarrhea resolve within 6 days of therapy (ST11 versus placebo: 76% vs 49%).

CONCLUSIONS

ST11 has a clinically significant benefit in the management of children with nonrotavirus-induced diarrhea, but it is ineffective in those with rotavirus diarrhea.

Low osmolar oral rehydration salts solution in the treatment of acute watery diarrhoea in neonates and young infants: a randomized, controlled clinical trial

To compare the efficacy and safety of low osmolar oral rehydration salts solution (ORS-75) (mmol/L: Na+ 75, osmolarity 245) with that of World Health Organization-recommended ORS (ORS-90) (mmol/L: Na+ 90, osmolarity 311 ) in the treatment of acute watery diarrhoea in neonates and very young infants, a randomized double-blind, controlled clinical trial was carried out at the Clinical Research and Service Centre of ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh, during January 1998-December 1999. Infants, aged < or = 2 months, presenting with a history of watery diarrhoea of < or = 72 hours, with no or some dehydration and without any systemic illness, were randomly assigned to receive either ORS-75 or ORS-90 for the correction and subsequent prevention of dehydration. Infants were studied for a maximum of five days. Total stool output, stool frequency, and requirement for ORS were outcome measures. Serum electrolytes were measured at 24 hours after admission to monitor serum sodium imbalance. Seventy-three infants received ORS-75, and 71 received ORS-90. Both the groups were comparable in their baseline characteristics. Diarrhoea resolved within five days in 53% and 66% of infants receiving ORS-75 and ORS-90 respectively (p = 0.3). Total stool volume [median (inter-quartile range) 132 (65-280) vs 139 (70-259) g/kg, p = 0.9], during the study period, was not significantly different between the two groups. Total stool frequency [31 (16-51) vs 35 (16-53), p = 0.9] and total ORS intake [192 (96-374) vs 209 (134-317) mL/kg, p = 0.7] were similar between the groups. No infants developed late evidence of hypernatraemia, irrespective of treatment. The results of the study indicate that ORS-75 is as safe as standard ORS-90 in the treatment of acute watery diarrhoea in neonates and very young infants and is effective in correcting and preventing dehydration.

High prevalence of cagA and vacA seropositivity in asymptomatic Bangladeshi children with Helicobacter pylori infection

AIM

To evaluate the prevalence of antibodies against two major markers of virulence of Helicobacter pylori--cytotoxin-associated gene A (cagA) and the vacuolating cytotoxin gene (vacA)--among children in a peri-urban community of Bangladesh, and to evaluate Western blot (WB) assay for detection of H. pylori infection diagnosed by 13C urea breath test (UBT) in such children.

METHODS

One hundred and eighty-two children aged 18-60 mo, of the peri-urban community of Dhaka, were screened for H. pylori infection using UBT, and the serum samples were analysed for antibody against cagA and vacA by Western blot.

RESULTS

The overall prevalence of H. pylori infection by 13C-urea breath test was 80%. The seroprevalence of cagA with or without vacA, vacA with and without cagA, and both cagA and vacA were 82%, 82% and 81%, respectively. Among children with a positive UBT, 95% were seropositive for both cagA and vacA, indicating that the products of these genes are frequently co-expressed in H. pylori infection in this community. The sensitivity, specificity, positive and negative predictive value of the Western blot test for H. pylori infections, compared to UBT, were 94%, 68%, 92% and 76%, respectively.

CONCLUSION

Compared to UBT, Western blot test is reliable for the detection of H. pylori infection. The high seroprevalence of cagA- and vacA-positive virulent H. pylori strains in an asymptomatic paediatric population indicate that such strains are common in this population and may cause characteristic H. pylori infection in Bangladesh.

High prevalence of cagA and vacA seropositivity in asymptomatic Bangladeshi children with Helicobacter pylori infection

AIM

To evaluate the prevalence of antibodies against two major markers of virulence of Helicobacter pylori--cytotoxin-associated gene A (cagA) and the vacuolating cytotoxin gene (vacA)--among children in a peri-urban community of Bangladesh, and to evaluate Western blot (WB) assay for detection of H. pylori infection diagnosed by 13C urea breath test (UBT) in such children.

METHODS

One hundred and eighty-two children aged 18-60 mo, of the peri-urban community of Dhaka, were screened for H. pylori infection using UBT, and the serum samples were analysed for antibody against cagA and vacA by Western blot.

RESULTS

The overall prevalence of H. pylori infection by 13C-urea breath test was 80%. The seroprevalence of cagA with or without vacA, vacA with and without cagA, and both cagA and vacA were 82%, 82% and 81%, respectively. Among children with a positive UBT, 95% were seropositive for both cagA and vacA, indicating that the products of these genes are frequently co-expressed in H. pylori infection in this community. The sensitivity, specificity, positive and negative predictive value of the Western blot test for H. pylori infections, compared to UBT, were 94%, 68%, 92% and 76%, respectively.

CONCLUSION

Compared to UBT, Western blot test is reliable for the detection of H. pylori infection. The high seroprevalence of cagA- and vacA-positive virulent H. pylori strains in an asymptomatic paediatric population indicate that such strains are common in this population and may cause characteristic H. pylori infection in Bangladesh.

Partially hydrolysed guar gum supplemented comminuted chicken diet in persistent diarrhoea: a randomised controlled trial

BACKGROUND

Partially hydrolysed guar gum (Benefiber) added to a diet is fermented in the colon, producing short chain fatty acids, which improve intestinal function, including colonic salt and water absorption.

AIMS

To evaluate the effect of Benefiber supplemented comminuted chicken diet in the treatment of persistent diarrhoea.

METHODS

One hundred and sixteen children (aged 5-24 months), presenting to Dhaka Hospital with a history of watery diarrhoea for more than 14 days (persistent diarrhoea), were randomised to receive either: (1) comminuted chicken diet with Benefiber (study diet); or (2) comminuted chicken diet without Benefiber (control diet). The study period was seven days.

RESULTS

Of 116 children, 57 received the study diet and 59 received the control diet. Diarrhoea resolved in a greater number of children with the study than with the control diet (46/55 (84%) v 36/58 (62%); odds ratio 3.12, 95% CI 1.19 to 8.4). Survival analysis for the duration of diarrhoea also showed a reduced duration of diarrhoea in children receiving the study diet. There was also a trend in daily stool reduction in children receiving the study diet, significant on days 4-7.

CONCLUSION

Results show that Benefiber supplemented comminuted chicken diet enhances recovery of children with persistent diarrhoea, indicating its therapeutic potential.

Helicobacter pylori infection, iron absorption, and gastric acid secretion in Bangladeshi children

BACKGROUND

Nonheme-iron absorption requires an acidic milieu. Reduced gastric acid output as a consequence of Helicobacter pylori infection could be an important limiting factor for iron absorption.

OBJECTIVE

We measured gastric acid output and iron absorption from a non-water-soluble iron compound (ferrous fumarate) and a water-soluble iron compound (ferrous sulfate) in children with and without H. pylori infection.

DESIGN

Gastric acid output was quantified before (basal acid output, or BAO) and after pentagastrin stimulation (stimulated acid output, or SAO) in 2-5-y-old children with iron deficiency anemia who were (n = 13) or were not (n = 12) infected with H. pylori. Iron absorption was measured by using a double-stable-isotope technique. H. pylori-infected children were studied before and after eradication therapy.

RESULTS

BAO and SAO were significantly lower in the H. pylori-infected children (0.2 +/- 0.2 and 1.6 +/- 0.9 mmol/h, respectively) than in the uninfected children (0.9 +/- 0.7 and 3.1 +/- 0.9 mmol/h, respectively; P = 0.01 and P < 0.005). BAO and SAO improved to 0.8 +/- 1.3 and 3.3 +/- 2.4 mmol/h, respectively, after therapy. Iron absorption from ferrous sulfate was significantly greater than that from ferrous fumarate both before (geometric : 19.7% compared with 5.3%; P < 0.0001) and after (22.5% compared with 6.4%; P < 0.0001) treatment in H. pylori-infected children. Corresponding values for uninfected children were 15.6% and 5.4%, respectively (P < 0.001; n = 12).

CONCLUSIONS

Iron absorption from ferrous fumarate was significantly lower than that from ferrous sulfate in both H. pylori-infected and uninfected Bangladeshi children. Treatment of H. pylori infection improved gastric acid output but did not significantly influence iron absorption. The efficacy of ferrous fumarate in iron fortification programs to prevent iron deficiency in young children should be evaluated.

Reduced osmolarity oral rehydration solution for persistent diarrhea in infants: a randomized controlled clinical trial

OBJECTIVE

We evaluated and compared the efficacy of the World Health Organization (WHO) oral rehydration solution (ORS) and 2 different formulations of reduced osmolarity ORSs in infants with persistent diarrhea.

STUDY DESIGN

Infants with persistent diarrhea (n = 95) were randomized to 1 of the 3 ORSs: WHO-ORS (control, n = 32), a glucose-based reduced osmolarity ORS (RORS-G, n = 30), or a rice-based reduced osmolarity ORS (RORS-R, n = 31) for replacement of ongoing stool losses for up to 7 days. Major outcome measures were stool volume and frequency, ORS intake, and resolution of diarrhea.

RESULTS

Although there were variations from one study day to another, the stool volume was approximately 40% less in the reduced osmolarity ORS groups; consequently, these children required less ORS (22% for RORS-G and 27% for RORS-R groups). A higher proportion of children in the RORS-R groups also had resolution of diarrhea during the study period. No children in any of the treatment groups had hyponatremia.

CONCLUSION

Reduced osmolarity ORS is clinically more effective than WHO-ORS and may thus be advantageous for use in the treatment of children with persistent diarrhea.

Characteristics of children hospitalized with severe dehydration and persistent diarrhoea in Bangladesh

The study analyzed data from a systematic sample of children, aged less than five years, who presented with persistent diarrhoea (diarrhoea of more than 14 days duration). It aims to differentiate (a) non-severe persistent diarrhoea (with no or mild dehydration) and (b) severe persistent diarrhoea (with moderate or severe dehydration), and to identify individual characteristics associated with severe persistent diarrhoea. In total, 7,505 patients, who represented a 4% systematic sample of the patient population, were seen during January 1993-December 1995. Of them, 297 (4%) presented with persistent diarrhoea. The male:female ratio was 2:1. Eighty-three percent of them had mild or no dehydration, and 17% had moderate or severe dehydration. Severe malnutrition of the study patients defined as weight-for-age z-score < -3, weight-for-length z-score < -3 and length-for-age z-score < -3 were 33.9%, 9.7%, and 22.7% respectively. Only 3% had oedematous malnutrition, and 11% had xerophthalmia. Factors independently associated with severe persistent diarrhoea by logistic regression analyses were: number of watery stool > 10 times during the last 24 hours prior to admission (OR, 10.0; CI, 1.2-87, p = 0.03), lower respiratory tract infection (OR, 111; CI, 4.2-2955, p = 0.004), and lack of mothers' education (OR, 7.8; CI, 1.4-41.9, p = 0.016) after controlling for confounders. Awareness and health education of mothers or caregivers and better case management during acute diarrhoeal episode might prevent the development of severe persistent diarrhoea in young children. In addition, children with severe persistent diarrhoea might need special attention to have adequate rehydration and control of extraintestinal infections, including respiratory tract infection.

Randomized, placebo-controlled, clinical trial of hyperimmunized chicken egg yolk immunoglobulin in children with rotavirus diarrhea

BACKGROUND

Hyperimmunized bovine colostrum containing antibodies has been shown to be effective in the treatment of rotavirus diarrhea. Antibodies derived from eggs of immunized hens may be a less expensive and more practical alternative. In this study, children with proven rotavirus diarrhea were treated with immunoglobulin extracted from eggs of chicken immunized with human rotavirus strains.

METHODS

In a randomized, double-blind study, 79 children with known rotavirus diarrhea were assigned to receive either 10 g hyperimmune egg yolk (HEY) daily in four equally divided doses for 4 days (HEY group) or a similar preparation obtained from nonimmunized chicken (placebo group). The daily stool frequency and amount, oral rehydration solution iORS) intake, and presence of rotavirus in the stool were monitored for 4 days.

RESULTS

In the HEY-treated group, there was significant reduction in stool output (in grams per kilogram per day; HEY vs. placebo; 87+/-59 vs. 120+/-75, P = 0.03), and significant reduction of ORS intake (in milliliters per kilogram per day) (HEY vs. placebo; 84+/-46 vs. 122+/-72, P = 0.008) on day 1 and clearance of virus on day 4 (HEY vs. placebo; 73% vs. 46%, P = 0.02). There was, however, no difference in diarrheal duration between the groups.

CONCLUSIONS

Treatment with HEY against four human rotavirus strains resulted in modest improvement of diarrhea associated with earlier clearance of rotavirus from stools. These results indicate an encouraging role of HEY in the treatment of rotavirus-induced diarrhea in children. Further studies are needed to optimize the dose and neutralization titer and thus improve the efficacy of egg yolk immunoglobulin IgY derived from immunized hens.

Partially hydrolyzed guar gum-supplemented oral rehydration solution in the treatment of acute diarrhea in children

BACKGROUND

Partially hydrolyzed guar gum (Benefiber; Novartis Nutrition, Minneapolis, MN, U.S.A.) is fermented by colonic bacteria liberating short-chain fatty acids (SCFAs), which accelerate colonic absorption of salt and water. The purpose of this study was to evaluate the effect of Benefiber (BF)-supplemented World Health Organization Oral Rehydration Solution (WHO ORS) in the treatment of acute noncholera diarrhea in children.

METHODS

A double-blind, randomized, controlled clinical trial was performed at ICDDR,B in 150 male children aged 4 to 18 months who had watery diarrhea of less than 48 hours' duration. After admission, children were assigned to receive either WHO ORS or BF-supplemented WHO ORS until recovery. Major outcome measures, such as duration of diarrhea and amount of stool output, were compared between the treatment groups.

RESULTS

Patients receiving BF-supplemented WHO ORS had significantly reduced duration of diarrhea compared with the control group (mean +/- SD, 74 +/- 37 vs. 90 +/- 50 hours, P = 0.03). Survival analysis for duration of diarrhea also showed a reduction the BF-supplemented WHO ORS-treated group (P = 0.025, log rank test). There was also less stool output daily from days 2 through 7 in the patients treated with BF-supplemented WHO ORS compared with that in the children treated with WHO ORS; the reduction was significant on day 7 only.

CONCLUSION

Benefiber added to standard WHO ORS substantially reduces the duration of diarrhea and modestly reduced stool output in acute noncholera diarrhea in young children, indicating its potential as a new antidiarrheal therapy for acute diarrhea in children.

Treatment of enterotoxigenic and enteropathogenic Escherichia coli-induced diarrhoea in children with bovine immunoglobulin milk concentrate from hyperimmunized cows: a double-blind, placebo-controlled, clinical trial

BACKGROUND

Enterotoxigenic Escherichia coli (ETEC) and enteropathogenic Escherichia coli (EPEC) are important causes of diarrhoea in young children and are associated with significant mortality rates. Passive immunization with antibodies from immunized cows has previously been shown to be effective as prophylaxis against E. coli-induced diarrhoea and therapeutically against rotavirus and cryptosporidia-induced diarrhoea.

METHODS

We tested the therapeutic efficacy of an oral bovine immunoglobulin milk concentrate (BIC) from cows hyperimmunized with ETEC and EPEC strains, in a randomized, placebo-controlled study in children with E. coli-induced diarrhoea. Eighty-six children between 4-24 months of age attending the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) with E. coli-induced diarrhoea (63 EPEC/ETEC and 23 with other diarrhoeagenic E. coli) were randomly assigned to receive orally administered BIC (20 g) containing anti-ETEC/EPEC antibodies or a placebo preparation daily for 4 consecutive days. Daily stool output, intake of oral rehydration solution (ORS), stool frequency, and presence of diarrhoeagenic E. coli strains in the stool were monitored for 4 days.

RESULTS

Children in the treatment group tolerated the BIC with no side effects. There were no significant differences between the two groups with regard to ORS intake, stool output, frequency of diarrhoea, or clearance of pathogen. Nor was there any significant alteration in the duration of diarrhoea.

CONCLUSIONS

In contrast to the prophylactic efficacy of anti-E. coli BIC and the therapeutic efficacy of a similarly prepared anti-rotavirus BIC, antibodies from hyperimmunized cows appear to have no significant therapeutic benefit in the treatment of acute diarrhoea due to EPEC/ETEC.

Evaluation of serology, 13C-urea breath test, and polymerase chain reaction of stool samples to detect Helicobacter pylori in Bangladeshi children

BACKGROUND

Serologic methods to detect Helicobacter pylori in infants, especially in developing countries, may be limited because of decreased immune response caused by malnutrition. The true prevalence may therefore be underestimated in this age group. Urea breath test is considered to be a good screening method in children but is expensive and therefore is not suitable for screening in developing countries. Simple, inexpensive, and accurate noninvasive methods to detect H. pylori in infants and young children are needed.

METHODS

Enzyme immunoassay (EIA) and immunoblot (IB) serologic analyses, 13C-urea breath test (UBT), and immunomagnetic separation--polymerase chain reaction (IMS-PCR) were performed on stool specimens, to detect H. pylori in 68 children between 4 and 24 months of age (mean, 11.5 months) in an endemic area in Bangladesh and the results compared.

RESULTS

The occurrence of H. pylori was 57% (n=39) using only UBT, 60% (n=41) using only IMS-PCR, and 78% (n=53) using UBT and IMS-PCR together. The concordance between UBT and IMS-PCR results was 62%. Immunoblot was positive in only 9% (n=6). Results in all 68 children were negative using EIA.

DISCUSSION

The prevalence of H. pylori infection in this periurban community and age group was high. Only serologic methods seem to be unsatisfactory for screening of H. pylori infection in infants and may not reflect the true prevalence. Immunomagnetic separation-PCR is a simple and rapid method for detection of H. pylori in stool and is an attractive method for analysis of colonization in infants. However, it may reflect a different stage of disease than UBT. Further studies are needed to clarify this.

Helicobacter pylori infection in infants and children of Bangladesh

Helicobacter pylori is an important cause of chronic gastritis and plays important roles in the etiology of peptic ulcer disease, gastric cancer and non-ulcer dyspepsia. While H. pylori infections occur worldwide, the great majority of information is from the developed countries, and little is known about the epidemiology of H. pylori in the developing countries, particularly in children.

Successful treatment of rotavirus diarrhea in children with immunoglobulin from immunized bovine colostrum

BACKGROUND

Oral ingestion of immunoglobulins in humans has been shown to be effective as prophylaxis against enteric infections. However, its therapeutic effect in children with infectious diarrhea has hitherto not been proven. We treated children with rotavirus diarrhea with immunoglobulins extracted from immunized bovine colostrum (IIBC) containing high titers of antibodies against four rotavirus serotypes.

METHODS

In this double blind placebo-controlled trial, 80 children with rotavirus diarrhea were randomly assigned to receive orally either 10 g of IIBC (containing 3.6 g of antirotavirus antibodies) daily for 4 days or the same amount of a placebo preparation. The daily stool output (grams/kg/day), intake of oral rehydration solution (ml/kg/day), stool frequency (number of stools/day) and presence of rotavirus in stool were monitored for the 4 days during treatment.

RESULTS

Children who received IIBC had significantly less daily and total stool output and stool frequency and required a smaller amount of oral rehydration solution than did children who received placebo (P < 0.05). Clearance of rotavirus from the stool was also earlier in the IIBC group compared with the placebo group (mean day, 1.5 vs. 2.9, P < 0.001). No adverse reactions from the colostrum treatment were observed.

CONCLUSIONS

Treatment with antirotavirus immunoglobulin of bovine colostral origin is effective in the management of children with acute rotavirus diarrhea.

Helicobacter pylori colonization in infants and young children is not necessarily associated with diarrhoea

A cohort of 151 infants and young children aged 1-23 months from a poor peri-urban community of Bangladesh was studied to determine the relationship between Helicobacter pylori colonization and morbidity due to diarrhoea. A 13C urea breath test was performed to detect the presence of H. pylori. Children were followed up at home every alternate day for 6 months and diarrhoeal morbidity data were collected. Diarrhoeal morbidity was compared between H. pylori-positive and H. pylori-negative children. Sixty-eight (45 per cent) children were H. pylori positive and 83 (55 per cent) were H. pylori negative. During the first 1-month period following the breath test, three (4.4 per cent) H. pylori-positive and four (4.8 per cent) H. pylori-negative children had diarrhoea. Thirty-two (47 per cent) of the children in the positive group and 43 (52 per cent) in the negative group had one or more episodes of diarrhoea during the 6-month follow-up period. Median number of diarrhoeal episodes was 1.0 (range 1.0-4.0) in the H. pylori-positive children and 2.0 (range 1.0-5.0) in the H. pylori-negative children (p = 0.19). No significant difference was observed in the cumulative days with diarrhoea. The results of this study suggest that H. pylori colonization is not associated with diarrhoeal morbidity in infants and young children.

Treatment of Helicobacter pylori infection in infants in rural Bangladesh with oral immunoglobulins from hyperimmune bovine colostrum

BACKGROUND

Antibodies from hyperimmune bovine colostrum have been shown to be effective in treatment against a variety of microorganisms, including Helicobacter pylori in adults.

AIM

To test this form of treatment in a small group of H. pylori infected children in a periurban community in Bangladesh.

METHODS

Twenty-four infants, 4-29 months old (mean age 16.5+/-7.7 months) and infected with H. pylori, were treated with purified immunoglobulins from hyperimmune bovine colostrum for 1 month, in a placebo-controlled, double-blind pilot study. Diagnosis was established with 13C-urea breath test (UBT) before and after the treatment period and at a 1-month follow-up.

RESULTS

None of the hyperimmune bovine colostrum-treated children became UBT negative. Five children initially positive in the UBT screening spontaneously became negative by the start of the study with hyperimmune bovine colostrum/placebo. At the end of the 1-month study period, three had became positive again.

CONCLUSION

Hyperimmune bovine colostrum does not eradicate H. pylori infection in infants. Transient H. pylori infection is common among infants in high endemic areas, as is reinfection after clearance. This presents obstacles to evaluation of therapeutic investigations in young children in areas where H. pylori is prevalent.

Helicobacter pylori: prevalence, transmission, and serum pepsinogen II concentrations in children of a poor periurban community in Bangladesh

The aim of this study was to determine the age-specific prevalence of Helicobacter pylori infection in infants and children aged 1-99 months from a poor periurban community in Bangladesh. We also examined the frequency of infection among infants and their 53 immediate family members and evaluated the relationship between infection and fasting serum group II pepsinogen (pepsinogen II) concentration in 76 children. Sixty-one percent of 1-3 month-old infants tested positive for H. pylori; this rate declined steadily to 33% in children aged 10-15 months and then increased to 84% in children aged 5-8 years. The H. pylori infection rate was 2.5 times higher in children with illiterate mothers. No difference in infection rate was detected among the family contacts of infected vs. noninfected infants. H. pylori-infected children had significantly higher serum pepsinogen II concentrations than did noninfected children (P < .001). We conclude that infection with H. pylori is highly prevalent and occurs at an early age. An environmental factor or factors, rather than or in addition to intrafamilial spread of this infection, are important in poor communities of Bangladesh. The higher levels of serum pepsinogen II in H. pylori-positive children might indicate the presence of gastritis in such asymptomatic children.

Noninvasive assessment of gastric acid secretion in man. Application of electrical impedance tomography (EIT)

Electrical impedance tomography (EIT) is a tubeless technique that generates tomographic images of gastric resistivity. We investigated the application of EIT to measure gastric acid secretion. Nineteen normal subjects underwent a standard intubation test. Basal acid output (BAO) and stimulated acid output (SAO) (millimoles per hour) were measured before and after pentagastrin, respectively. On a different day, EIT was performed before (basal) and after pentagastrin (stimulated). The changes in impedance over time were measured and the area under the curve (AUC) was calculated. Both the tests were repeated in 13 subjects after omeprazole treatment. As in the intubation test, there was the expected increase in AUC value after pentagastrin (basal vs stimulated; 1.2 +/- 2.8 vs 731 +/- 297, P < 0.0001). A significant fall in acid output and AUC following omeprazole pretreatment was observed (without vs with omeprazole; 20.5 +/- 5.7 vs 0.03 +/- 0.06, P < 0.0001 for intubation test and 731 +/- 297 vs 44 +/- 172, P < 0.0001 for EIT). There was a significant correlation between SAO and the delta AUC with (r = 0.65 P < 0.001) or without (r = 0.95, P < 0.001) omeprazole and in all the experiments (r = 0.87, P < 0.001). This study demonstrates the predictable change of gastric impedance and may be useful as a noninvasive test for measuring gastric acid secretion.

Helicobacter pylori infection in the young in Bangladesh: prevalence, socioeconomic and nutritional aspects

BACKGROUND

The gastric acid barrier, an important host defence against small bowel infection, may be compromised by infection with Helicobacter pylori. In developing countries, H. pylori infection occurs early in life and prevalence of hypochlorhydria is high particularly in the malnourished, which may predispose a child to repeated gastrointestinal infection and diarrhoea. Diarrhoea being a leading cause of childhood mortality and morbidity in developing countries, we investigated the prevalence of H. pylori infection in children in a poor Bangladeshi community and explored its association with socioeconomic and nutritional status.

METHODS

The study was conducted in a poor periurban community among 469 children aged 1-99 months. Parents were interviewed using a questionnaire. To detect active infection with H. pylori a 13C-urea breath test was performed and weight was recorded on a beam balance with a sensitivity of 20 g.

RESULTS

In all, 61% of 36 infants aged 1-3 months were positive for H. pylori; this rate dropped steadily with increasing age and was 33% in 10-15 month old children and then rose to 84% in 6-9 year olds. Overall H. pylori infection had no association with nutritional state of the child, or family income but the infection rate was 2.5 times higher in children of mothers with no schooling.

CONCLUSIONS

The H. pylori infection rate is very high in early infancy in a poor periurban community of Bangladesh. The reason for a drop in the infection rate in late infancy is unclear but could be due to initial clearance of the infection by the body's defence mechanisms but with possible alteration of the gastric mucosa which sustains infection. Maternal education may be protective and may operate through some unidentified proximate behavioural determinants. The rate of H. pylori infection in infants and young children may predispose them to repeated gastrointestinal infection and diarrhoea.

Prevalence of Helicobacter pylori infection in infants and family contacts in a poor Bangladesh community

Although H. pylori is well established as an etiological agent of type B gastritis and a predisposing factor for peptic ulcer, knowledge about its transmission is unclear. In this study we examined the prevalence of H. pylori infection in the family members of index infants infected with this organism as indicated by positive [13C]-urea breath test (UBT). We performed UBT among family members of 15 predominantly breastfed infants, eight with and seven without H. pylori infection. Infection rates were 82% and 91% in family contacts of the infected and noninfected infants respectively, the average infection rate being 85%, which is rated to be high. There was no difference in infection rates among the parents of the infected and noninfected infants. Fifty percent and 70% families belonging to infected and noninfected infants, respectively, were found to have all members infected with H. pylori. No evidence of sex predilection of infection was found. We conclude that in communities with high prevalence of H. pylori infection, there is almost an equal infection rate among the family contacts of infected and noninfected infants, suggesting that environmental factors may be more important than intrafamilial transmission.

Septicemia due to Vibrio cholerae 0139 Bengal

We describe septicemia due to Vibrio cholerae 0139 Bengal, the newly described causative agent of cholera, in a child who also had simultaneous intestinal infection with Shigella boydii. Because V. cholerae 0139 is capsulated, its propensity to cause extraintestinal infection is stressed.

Alanine- and glucose-based hypo-osmolar oral rehydration solution in infants with persistent diarrhoea: a controlled trial

To evaluate the efficacy of a hypo-osmolar and a standard (World Health Organization) oral rehydration salt (ORS) solution in persistent diarrhoea, a randomized controlled clinical trial was conducted in 55 children. After a 1-day observation period the children were assigned to one of three solutions: standard ORS (WHO-ORS) (osmolality 311 mosmol/l), hypo-osmolar ORS containing L-alanine and glucose (osmolality 255 mosmol/l) and i.v. polyelectrolyte solutions (osmolality 293 mosmol/l) for ongoing replacement of stool loss for the next 4 days. Excellent acceptability of ORS (101-160 ml/kg body weight/day) by the children was observed. There were no significant differences in the total intake of solutions and food, and frequency of stools among the groups. Stool outputs were significantly less in infants receiving hypo-osmolar ORS than in those receiving WHO-ORS for 0-24 h (p = 0.04), 0-48 h (p = 0.01), 0-72 h (p = 0.04) and 0-96 h (p = 0.03). The results indicate a sufficient scope of ORS practice in persistent diarrhoea. Furthermore, we found that a hypo-osmolar ORS containing L-alanine and glucose is as efficacious as an iv solution and more effective than WHO-ORS for replacement of ongoing stool loss in persistent diarrhoea.

The presence of bicarbonate in oral rehydration solution does not influence fluid absorption in cholera

BACKGROUND

On the basis of human perfusion studies it has been speculated that bicarbonate ions in oral rehydration salt solutions (ORS) to treat diarrhoea are more efficiently absorbed from the small bowel. We evaluated the role of bicarbonate in ORS by using a reduced purging rate in cholera as a proxy indicator for absorption efficiency in cholera-like severe diarrhoea.

METHODS

In a double-blind randomized trial 60 patients received standard ORS containing bicarbonate or an identical solution except that sodium bicarbonate was replaced by an equimolar amount of sodium chloride (sodium, 90 mmol/l; potassium, 20 mmol/l; chloride, 80 mmol/l; bicarbonate, 30 mmol/l; glucose, 111 mmol/l; and osmolality, 331 mmol/l) after initial intravenous rehydration to correct initial dehydration and shock and until diarrhoea ceased.

RESULTS

Five patients receiving standard ORS and eight receiving bicarbonate-free ORS required unscheduled intravenous therapy for recurrence of severe dehydration in spite of receiving ORS solution. ORS intake and purging rate, in ml/kg body weight/day, both including and excluding stool output during unscheduled intravenous therapy are closely similar in the two treatment groups.

CONCLUSION

The results indicate that bicarbonate-containing ORS solution does not have any clinically significant effect on the absorption efficiency of ORS, either beneficial or adverse, and its use is relevant only for correction of metabolic acidosis of diarrhoeal dehydration.

Enteric protein loss and intestinal permeability changes in children during acute shigellosis and after recovery: effect of zinc supplementation

The effect of zinc supplementation on intestinal permeability changes and protein loss was studied in 32 children aged between 1 and 12 years during bouts of acute shigellosis and after recovery. An intestinal permeability test and then a 48 hour balance study were performed on all patients. They were then blindly assigned to receive vitamin B syrup either with or without zinc acetate (15 mg/kg per day) for a month. All patients received a five day course of nalidixic acid. The balance study was repeated during convalescence and follow up, but a permeability test was done only at follow up after one month. Intestinal permeability, expressed as a urinary lactulose:mannitol excretion ratio, improved significantly (p = 0.001) along with a significant increase (p = 0.005) in mannitol excretion in the zinc supplemented children, suggesting a resolution of small bowel mucosal damage. The latter was associated with a higher coefficient of nitrogen absorption (p = 0.03), suggesting a possible role of zinc in the treatment of shigellosis. Enteric protein loss, as assessed by faecal alpha 1 antitrypsin clearance, was not influenced by zinc supplementation.

Non-immunological defence mechanisms of the gut

Non-immunological defence mechanisms represent an important line of intestinal defence in addition to humoral and cellular immunity. This review summarises the evidence for the role of the non-immunological defence system. Protective factors that have been amply documented are gastric juice, intestinal motility, and intestinal flora. Components of pancreatic juice, lysozyme, and epithelial cell turnover may also be involved. Special attention is given to gastric acid, infection with Helicobacter pylori, and hypochlorhydria and their association with infectious diarrhoea. Epidemic hypochlorhydria is discussed since this increases sensitivity to intestinal infections in third world countries.

Hydrolysed wheat based oral rehydration solution for acute diarrhoea

A randomised three cell study was carried out in 78 children with acute diarrhoea to evaluate the relative efficacy of oral rehydration solution (ORS) made from partially hydrolysed wheat grain, cooked rice powder, or glucose. Twenty six patients with comparable age, body weight, duration of diarrhoea, and degree of dehydration were studied in each of the three groups. Initial rehydration was carried out by using intravenous Dhaka solution within one to two hours followed by administration of oral rehydration solution. The mean ORS intake during the first and second 24 hours of treatment in patients with cholera receiving wheat-ORS and rice-ORS was significantly less compared with those receiving glucose-ORS. The stool output during the same period in patients receiving wheat-ORS and rice-ORS was significantly less compared with those receiving glucose-ORS. Similar trends in both ORS intake and stool output were observed during the next 24 hours.