Impact of Rotaviral Diarrhea on Child Growth in Sub-Saharan Africa and South Asia in the Global Enteric Multicenter Study.

Rotavirus is the leading cause of dehydrating diarrhea among children in developing countries. The impact of rotaviral diarrhea on nutritional status is not well understood. We aimed to determine the association between rotavirus-positive moderate-to-severe diarrhea and nutrition in children under 5 years of age. We analyzed data from the Global Enteric Multicenter Study on children 0-59 months old from South Asia and sub-Saharan Africa. The relationships between explanatory variables and outcome variables were assessed using multiple linear regression; the explanatory variable was the presence of rotavirus in the stool sample, and the outcome variables were z scores [length/height-for-age (LAZ/HAZ), weight-for-age (WAZ), and weight-for-length/height (WLZ/WHZ)] at follow-up (∼60 days). The prevalence of rotaviral diarrhea was 17.3% (905/5,219) in South Asia and 19.95% (842/4,220) in sub-Saharan Africa. Rotavirus was associated with higher LAZ/HAZ (ß: 0.19; 95% CI: 0.12, 0.26; P <0.001) and WAZ (ß: 0.15; 95% CI: 0.79, 0.22; P <0.001) in sub-Saharan Africa and with lower WLZ/WHZ (ß coefficient: -0.08; 95% CI: -0.15, -0.009; P = 0.027) in South Asia. Our study indicates that rotaviral diarrhea is positively associated with nutritional status in sub-Saharan Africa and is negatively associated with nutritional status in South Asia. An expedited implementation policy of ongoing preventive and control strategies, including vaccination against rotavirus, is necessary to reduce the burden of rotaviral diarrhea, which may further help to reduce the potential nutritional ramifications.

Changing Water-Sanitation Determinants of Cholera over Two Decades in Bangladesh.

Cholera is a leading global public health threat, especially in developing countries. This study aimed to determine the changing determinants of cholera related to water-sanitation practices between 1994-1998 and 2014-2018 in Dhaka, Bangladesh. Data of all cause diarrhea cases were extracted from the Diarrheal Disease Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, and analysis was performed among three groups: Vibrio cholerae detected as sole pathogen, V. cholerae detected as mixed infection, and detection of no common enteropathogen in stool specimens (reference). Using sanitary toilet, drinking tap water, drinking boiled water, family size greater than five, and slum dwelling were the main exposures. Overall, 3,380 (20.30%) and 1,290 (9.69%) patients were positive for V. cholerae during 1994-1998 and 2014-2018, respectively. In 1994-1998, use of sanitary toilet (adjusted odds ratio [aOR]: 0.86, 95% CI: 0.76-0.97) and drinking tap water (aOR: 0.81, 95% CI: 0.72-0.92) were found to be negatively associated and in 2014-2018, drinking tap water (aOR: 1.47, 95% CI: 1.21-1.78) and slum dwelling (aOR: 1.43, 95% CI: 1.10-1.86) were found to be positively associated with V. cholerae infection after adjusting for age, sex, monthly income, and seasonality. Because the determinants of cholera such as drinking tap water can change over time in developing cities, ameliorating the water, sanitation, and hygiene (WASH) situation is of paramount importance. In addition, in settings such as urban slums, where long-term WASH monitoring might be difficult to achieve, mass vaccination with oral cholera vaccine should be introduced to control cholera.

Symptomatic and Asymptomatic Campylobacter Infections and Child Growth in South Asia: Analyzing Data from the Global Enteric Multicenter Study.

Campylobacter is a major cause of food-borne gastrointestinal illnesses worldwide, predominantly affecting children under 5 years of age. This study examined potential associations of symptomatic (with diarrhea) and asymptomatic (without diarrhea) Campylobacter infections with child growth among children under 5 years of age in South Asia. The Global Enteric Multicenter Study was conducted from 2007 to 2011 with a case-control design. Children were followed for 60 days after enrollment. Stool culture was performed to isolate Campylobacter spp. Among the 22,567 enrolled children, 9,439 were symptomatic, with 786 (8.28%) testing positive for Campylobacter. Conversely, 13,128 asymptomatic healthy controls were included, with 1,057 (8.05%) testing positive for Campylobacter. Growth faltering was observed in the symptomatic group, particularly among children aged 0-11 months (-0.19 height-for-age z score [HAZ]; 95% CI: -0.36, -0.03; P = 0.018) and 24-59 months (-0.16 HAZ; 95% CI: -0.28, -0.04; P = 0.010). However, in the asymptomatic group, growth faltering was observed only in the 24- to 59-month age group, in terms of HAZ (-0.15 HAZ; 95% CI: -0.24, -0.05; P = 0.002) and weight-for-height z score (-0.16; 95% CI: -0.26, -0.06; P = 0.001). These findings underscore the importance of immediate and enhanced introduction of preventive modalities to reduce the burden of Campylobacter infections and reduce their long-term sequelae.

Vibrio cholerae in rural and urban Bangladesh, findings from hospital-based surveillance, 2000-2021.

With more than 100,000 cases estimated each year, Bangladesh is one of the countries with the highest number of people at risk for cholera. Moreover, Bangladesh is formulating a countrywide cholera-control plan to satisfy the GTFCC (The Global Task Force on Cholera Control) Roadmap's goals. With a particular focus on cholera trends, variance in baseline and clinical characteristics of cholera cases, and trends in antibiotic susceptibility among clinical isolates of Vibrio cholerae, we used data from facility-based surveillance systems from icddr,b's Dhaka, and Matlab Hospitals from years 2000 to 2021. Female patients comprised 3,553 (43%) in urban and 1,099 (51.6%) in rural sites. Of the cases and most patients 5,236 (63.7%) in urban and 1,208 (56.7%) in the rural site were aged 15 years and more. More than 50% of the families belonged to the poor and lower-middle-class; in 2009 (24.4%) were in urban and in 1,791 (84.2%) were in rural sites. In the urban site, 2,446 (30%) of households used untreated drinking water, and 702 (9%) of families disposed of waste in their courtyard. In the multiple logistic regression analysis, the risk of cholera has significantly increased due to waste disposal in the courtyard and the boiling of water has a protective effect against cholera. Rotavirus (9.7%) was the most prevalent co-pathogen among the under-5 children in both sites. In urban sites, the percentage of V. cholerae along with co-existing ETEC and Campylobacter is changing in the last 20 years; Campylobacter (8.36%) and Enterotoxigenic Escherichia coli (ETEC) (7.15%) were the second and third most prevalent co-pathogens. Shigella (1.64%) was the second most common co-pathogen in the rural site. Azithromycin susceptibility increased slowly from 265 (8%) in 2006-2010 to 1485 (47.8%) in 2016-2021, and erythromycin susceptibility dropped substantially over 20 years period from 2,155 (98.4%) to 21 (0.9%). Tetracycline susceptibility decreased in the urban site from 2051 (45.9%) to 186 (4.2%) and ciprofloxacin susceptibility decreased from 2,581 (31.6%) to 1,360 (16.6%) until 2015, then increased 1,009 (22.6%) and 1,490 (18.2%) in 2016-2021, respectively. Since 2016, doxycycline showed 902 (100%) susceptibility. Clinicians need access to up-to-date information on antimicrobial susceptibility for treating hospitalized patients. To achieve the WHO-backed objective of eliminating cholera by 2030, the health systems need to be put under a proper surveillance system that may help to improve water and sanitation practices and deploy oral cholera vaccines strategically.

Antimicrobial resistance in shigellosis: A surveillance study among urban and rural children over 20 years in Bangladesh.

Antimicrobial resistance against shigellosis is increasingly alarming. However, evidence-based knowledge gaps regarding the changing trends of shigellosis in Bangladesh exist due to the scarcity of longitudinal data on antimicrobial resistance. Our study evaluated the last 20 years antimicrobial resistance patterns against shigellosis among under-5 children in the urban and rural sites of Bangladesh. Data were extracted from the Diarrheal Disease Surveillance System (DDSS) of Dhaka Hospital (urban site) and Matlab Hospital (rural site) of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) between January 2001 and December 2020. We studied culture-confirmed shigellosis cases from urban Dhaka Hospital (n = 883) and rural Matlab Hospital (n = 1263). Since 2001, a declining percentage of shigellosis in children observed in urban and rural sites. Moreover, higher isolation rates of Shigella were found in the rural site [1263/15684 (8.1%)] compared to the urban site [883/26804 (3.3%)] in the last 20 years. In both areas, S. flexneri was the predominant species. The upward trend of S. sonnei in both the study sites was statistically significant after adjusting for age and sex. WHO-recommended 1st line antibiotic ciprofloxacin resistance gradually reached more than 70% in both the urban and rural site by 2020. In multiple logistic regression after adjusting for age and sex, ciprofloxacin, azithromycin, mecillinam, ceftriaxone, and multidrug resistance (resistance to any two of these four drugs) among under-5 children were found to be increasing significantly (p<0.01) in the last 20 years in both sites. The study results underscore the importance of therapeutic interventions for shigellosis by appropriate drugs based on their current antibiogram for under-5 children. These observations may help policymakers in formulating better case management strategies for shigellosis.

Water, Sanitation, and Hygiene (WASH) Practices and Outreach Services in Settlements for Rohingya Population in Cox's Bazar, Bangladesh, 2018-2021.

(1) Background: This study aimed to investigate the existing water, sanitation, and hygiene (WASH) policy and practice of the study population and strengthen the evidence base by documenting changes in the WASH policy and practice over 3 years of the Rohingya refugee humanitarian crisis, Cox's Bazar, Bangladesh. (2) Methods: A cross-sectional surveillance design was followed; the sampling of the study population included the Rohingya refugee population and neighborhood host nationals who required hospitalization soon after seeking care and enrolled into the diarrheal disease surveillance in diarrhea-treatment centers. Throughout the study period of 3 years, a total of 4550 hospitalized individuals constituted the study participants. (3) Results: Among the hospitalized Rohingya refugee population; the use of public tap water increased significantly from 38.5% in year 1 to 91% in year 3. The use of deep tube well water significantly changed from 31.3% to 8.2%, and the use of shallow tube well water reduced significantly from 25.8% to 0.4%. Households using water seal latrine were 13.3% in year 1 and increased significantly to 31.7% in year 3. ORS consumption at home changed significantly from 61.5% in the first year to 82.1% in third year. Multivariable analysis demonstrated patients' age groups at 5 to 14 years, and 15 years and more, drinking non-tube well water, soap use after using toilet, use of non-sanitary toilet facility, father's and mother's lack of schooling, and some and severe dehydration were significantly associated with the Rohingya refugee population enrolled into the diarrheal disease surveillance. (4) Conclusion: The findings indicate significant advances in WASH service delivery as well as outreach activities by aid agencies for the Rohingya refugee population living in settlements.

Different Features of Cholera in Malnourished and Non-Malnourished Children: Analysis of 20 Years of Surveillance Data from a Large Diarrheal Disease Hospital in Urban Bangladesh.

Malnourished children are more prone to infectious diseases including severe diarrhea compared to non-malnourished children. However, data are scarce on differences in the presentation in such children. We aimed to identify clinical differentials among children with cholera with or without malnutrition. Data were extracted from the diarrheal disease surveillance system (DDSS) of Dhaka Hospital of International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) from January 2001 to December 2020. Among children under five in DDSS, cholera positive (culture confirmed) malnourished children (WAZ, WL/HZ or L/HAZ ˂ -2) were considered as cases (n = 920) and children with cholera but non-malnourished (WAZ, WL/HZ or L/HAZ ≥-2.00 to ≤+2.00) were controls (n = 586). After adjusting for potential confounders such as maternal illiteracy, day labor fathers, maternal employment, slum dwelling, non-sanitary latrine use, use of untreated water, and history of cough, it was revealed that malnourished cholera children significantly more often presented in hospital during evening hours (6 p.m. to 12 mid-night) (p < 0.05), had illiterate fathers (p < 0.05), >24 h history of diarrheal duration (p < 0.05), dehydrating diarrhea (p < 0.05), and had longer hospitalization (p < 0.05). The study results underscore the importance of understanding of basic differences in the presentation of severity of cholera in malnourished children for prompt identification and subsequent management of these vulnerable children.

Anthropometric Indices of Giardia-Infected Under-Five Children Presenting with Moderate-to-Severe Diarrhea and Their Healthy Community Controls: Data from the Global Enteric Multicenter Study.

Among all intestinal parasitosis, giardiasis has been reported to be associated with delayed growth in malnourished children under 5 living in low- and middle-income countries. Relevant data on the nutritional status of children aged 0-59 months presenting with moderate-to-severe diarrhea (MSD) and giardia infection were collected from sentinel health facilities of the Global Enteric Multicenter Study's (GEMS) seven field settings, placed in diverse countries of Sub-Saharan Africa and South Asia between, December 2007 and February 2011. Then, this study analyzed a robust dataset of study participants (n = 22,569). Children having giardiasis with MSD constituted as cases (n = 1786), and those without MSD constituted as controls (n = 3470). Among the seven field sites, symptomatic giardiasis was 15% and 22% in Asian and African sites, respectively, whereas asymptomatic giardia infection (healthy without MSD) in Asian and African sites was 21.7% and 30.7%, respectively. Wasting and underweight were more frequently associated and stunting less often associated with symptomatic giardiasis (for all, p < 0.001). Symptomatic giardiasis had a significant association with worsening of nutritional status in under-five children. Improved socio-economic profile along with proper sanitation and hygienic practices are imperative to enhance child nutritional status, particularly in resource limited settings.

Characteristics of Rotavirus, ETEC, and Vibrio Cholerae Among Under 2-year Children Attending an Urban Diarrheal Disease Hospital in Bangladesh.

BACKGROUND: Information on comparative clinical and host characteristics of under-2 children with watery diarrhea caused by rotavirus, Enterotoxigenic Escherichia coli (ETEC), and Vibrio cholerae as single pathogens is lacking. We sought to investigate the sociodemographic, clinical, and host characteristics of under-2 children hospitalized due to these pathogens. METHODOLOGY: We conducted a hospital-based case-control study using the icddr,b Diarrheal Diseases Surveillance System. Children of either sex, <2 years with diarrhea, who attended the hospital during 2014 to 2018, constituted the study population. Stool specimens having a single pathogen like rotavirus, ETEC, or Vibrio cholerae constituted the cases and stool specimens having no detectable common enteropathogens comprised the controls. Multinomial logistic regression analysis was done where control was the reference group. RESULTS: A total of 14 889 patients were enrolled, 6939 of whom were under-2 children, and 5245 (76%) constituted our study population. Among them 48% (n = 2532), 3% (n = 148) and 1% (n = 49) had rotavirus, ETEC, and Vibrio cholera, respectively. A control group (diarrhea without these 3 or Shigella, Salmonella, Aeromonas) accounted for 48% (n = 2516). In multinomial regression model, children with rotavirus (adjusted odds ratio [aOR], 1.36; 95% confidence interval [95% CI], 1.19-1.55) less often presented with dehydrating diarrhea compared to those with ETEC (aOR, 1.54; 95% CI, 1.05-2.26) and cholera (aOR, 2.25; 95% CI, 1.11-4.57). Rotavirus diarrhea was associated (aOR, 1.25; 95% CI, 1.07-1.46) with those who received antimicrobials prior to hospital admission and protectively associated with drinking tap water (aOR, 0.84; 95% CI, 0.73-0.95); however, ETEC diarrhea had protective association (aOR, 0.62; 95% CI, 0.43-0.92) with children who received antimicrobials prior to hospital admission and was associated with drinking tap water (aOR, 1.78; 95% CI, 1.19-2.66). Use of intravenous fluid was associated with cholera (aOR, 10.36; 95% CI, 4.85-22.16) and had protective association with rotavirus episodes (aOR, 0.64; 95% CI, 0.45-0.91). CONCLUSIONS: Clinical presentations and host characteristics of rotavirus, ETEC, and Vibrio cholerae diarrhea differed from each other and the information may be helpful for clinicians for better understanding and proper management of these children.

Vibrio cholerae O139 persists in Dhaka, Bangladesh since 1993.

BACKGROUND: After a multi-country Asian outbreak of cholera due to Vibrio cholerae serogroup O139 which started in 1992, it is rarely detected from any country in Asia and has not been detected from patients in Africa. METHODOLOGY/PRINCIPAL FINDINGS: We extracted surveillance data from the Dhaka and Matlab Hospitals of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) to review trends in isolation of Vibrio cholerae O139 in Bangladesh. Data from the Dhaka Hospital is a 2% sample of > 100,000 diarrhoeal patients treated annually. Data from the Matlab Hospital includes all diarrhoeal patients who hail from the villages included in the Matlab Health and Demographic Surveillance System. Vibrio cholerae O139 was first isolated in Dhaka in 1993 and had been isolated every year since then except for a gap between 2005 and 2008. An average of thirteen isolates was detected annually from the Dhaka Hospital during the last ten years, yielding an estimated 650 cases annually at this hospital. During the last ten years, cases due to serogroup O139 represented 0.47% of all cholera cases; the others being due to serogroup O1. No cases with serogroup O139 were identified at Matlab since 2006. Clinical signs and symptoms of cholera due to serogroup O139 were similar to cases due to serogroup O1 though more of the O139 cases were not dehydrated. Most isolates of O139 remained sensitive to tetracycline, ciprofloxacin, and azithromycin, but they became resistant to erythromycin starting in 2009. CONCLUSIONS/SIGNIFICANCE: Cholera due to Vibrio cholerae serogroup O139 continues to cause typical cholera in Dhaka, Bangladesh.

Cholera outbreak in Forcibly Displaced Myanmar National (FDMN) from a small population segment in Cox's Bazar, Bangladesh, 2019.

BACKGROUND: Bangladesh experienced a sudden, large influx of forcibly displaced persons from Myanmar in August 2017. A cholera outbreak occurred in the displaced population during September-December 2019. This study aims to describe the epidemiologic characteristics of cholera patients who were hospitalized in diarrhea treatment centers (DTCs) and sought care from settlements of Forcibly Displaced Myanmar Nationals (FDMN) as well as host country nationals during the cholera outbreak. METHODS: Diarrhea Treatment Center (DTC) based surveillance was carried out among the FDMN and host population in Teknaf and Leda DTCs hospitalized for cholera during September-December 2019. RESULTS: During the study period, 147 individuals with cholera were hospitalized. The majority, 72% of patients reported to Leda DTC. Nearly 65% sought care from FDMN settlements. About 47% of the cholera individuals were children less than 5 years old and 42% were aged 15 years and more. Half of the cholera patients were females. FDMN often reported from Camp # 26 (45%), followed by Camp # 24 (36%), and Camp # 27 (12%). Eighty-two percent of the cholera patients reported watery diarrhea. Some or severe dehydration was observed in 65% of cholera individuals. Eighty-one percent of people with cholera received pre-packaged ORS at home. About 88% of FDMN cholera patients reported consumption of public tap water. Pit latrine without water seal was often used by FDMN cholera individuals (78%). CONCLUSION: Vigilance for cholera patients by routine surveillance, preparedness, and response readiness for surges and oral cholera vaccination campaigns can alleviate the threats of cholera.

Changing trends in nutritional status of adolescent females: a cross-sectional study from urban and rural Bangladesh.

OBJECTIVES: Malnutrition remains a major problem among adolescents worldwide, but the types of nutritional problem impacting this group are changing significantly. This study aims to describe and analyse the trends in nutritional status and related epidemiological characteristics of 10 to 19 years old adolescent girls over time (2001 to 2018) in Bangladesh. METHODS: We extracted data from the Diarrhoeal Disease- Surveillance System of the International Centre for Diarrhoeal Disease Research Bangladesh. We performed χ2 test for trend to test for statistical significance of the changing trends of undernutrition and overnutrition among the study participants. Multivariable logistic regression model was fit to measure the strength of association, reported as adjusted OR (aOR) and corresponding 95% CIs. RESULTS: A total of 1224 and 628 adolescent females attended urban and rural treatment facilities, respectively, between 2001 and 2018. The proportion of stunting and thinness decreased substantially, whereas overweight has been observed to increase (1.7% to 7.4%, p<0.001) over the study period. Factors independently associated with stunting were illiteracy (aOR 2.39, 95% CI (1.68 to 3.39), p<0.001), monthly family income of less than US$100 (aOR 1.54, 95% CI (1.25 to 1.9), p<0.001) and family belonging to poorest wealth quintile (aOR 1.45, 95% CI (1.13 to 1.87), p=0.004). Younger participants (aOR 2.69, 95% CI (2.10 to 3.45), p<0.001), rural participants (aOR 1.71 95% CI (1.23 to 2.38), p<0.001), longer hospital stay (aOR 1.52, 95% CI (1.16 to 1.98), p=0.002) and monthly family income less than US$100 (aOR 1.44, 95% CI (1.09 to 1.89), p=0.009) were significantly associated with thinness. Conversely, overweight/obesity was associated with monthly family income more than US$100, duration of diarrhoea and rural participants. CONCLUSION: Undernutrition in adolescent girls has decreased with time, but the burden of overweight has increased. Higher literacy and better wealth status were found to be associated with the improved nutritional status of the participants.

Gender disparity in care-seeking behaviours and treatment outcomes for dehydrating diarrhoea among under-5 children admitted to a diarrhoeal disease hospital in Bangladesh: an analysis of hospital-based surveillance data.

INTRODUCTION: Despite economic development and augmented literacy rates, Bangladeshi households are still discriminating against girls when it comes to seeking medical care. We examined gender disparities in diarrhoeal disease severity and the treatment outcomes of under-5 children. SETTING: A tertiary level diarrhoeal disease hospital in Dhaka, Bangladesh. PARTICIPANTS: 13 361 under-5 children admitted to the hospital between January 2008 and December 2017. OUTCOME VARIABLES AND METHODS: The primary outcome of interest was severity of diarrhoea, defined as 'dehydrating diarrhoea' or 'non-dehydrating diarrhoea'. Multivariable logistic regression analyses were performed to assess the association between 'gender' and admission to hospital for dehydrating diarrhoea. RESULTS: Data on 13 321 children under 5 years of age were analysed, of whom 61.5% were male and 38.5% were female. The mean (±SD) age of children with diarrhoea was 5.63 (±3.49) months. The median distance travelled to come to the hospital for admission was 10 miles (IQR: 6-25) and was significantly higher for boys (10 miles, IQR: 6-25) than girls (9.5 miles, IQR: 6-23) (p<0.001). Girls had 1.11 times higher odds (adjusted OR: 1.11, 95% CI 1.03 to 1.20, p=0.007) of presenting with dehydrating diarrhoea than boys at the time of hospital admission. Almost 20% of children received two or more medications during the period of hospital admission and this did not differ by gender. The median duration of hospital stay was 11 hours and was similar in both sexes. No gender-based disparity was observed in the management of diarrhoea and in the hospital outcome of children. CONCLUSION: We found that girls were more likely to have dehydrating diarrhoea when they were presented to the Dhaka hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. No gender-based disparity was observed in the hospital outcome of children.

Pathogen-specific risk of seizure in children with moderate-to-severe diarrhoea: Case control study with follow-up.

OBJECTIVE: To determine the pathogen-specific risk of seizure in under-five children hospitalised with moderate-to-severe diarrhoea (MSD) in rural settings. METHOD: This was a prospective case-control study with follow-up, conducted in a sentinel facility of Global Enteric Multicenter Study in Mirzapur, a rural community of Bangladesh between 2007 and 2010. Children aged 0-59 months who presented with MSD and seizure constituted the cases whereas those who did not have seizure comprised the controls. MSD was defined if the episodes were associated with dehydration or dysentery or required hospitalisation with diarrhoea or dysentery. All enrolled children were followed up at home within 50-90 days of enrolment. A total of 64 cases and 128 randomly selected controls formed the analysable dataset. RESULTS: The result of logistic regression analysis after adjusting for potential confounders revealed that shigellosis (Shigella species, OR = 5.34, 95% CI = 2.37-12.04) particularly S. flexneri (OR = 3.34, 95% CI = 1.48-7.57), S. flexneri 6 (OR = 23.24, 95% CI = 2.79-193.85), S. sonnei (OR = 6.90, 95% CI = 2.34-19.85); norovirus (OR = 6.77, 95% CI = 1.69-27.11), fever (OR = 16.75, 95% CI = 1.81-154.70) and loss of consciousness (OR = 35.25, 95% CI = 1.71-726.20) were the independent risk factors for seizure in MSD children. At enrolment, cases had lower WHZ (P = 0.006) compared to their peers, follow-up anthropometrics showed significant improvement in WHZ (P < 0.001) and WAZ (P < 0.05), whereas deterioration in HAZ (P < 0.001) in both cases and controls. CONCLUSION: Childhood MSD episodes particularly due to Shigella and norovirus are often associated with seizure. Prompt identification and appropriate management of children with shigellosis may reduce occurrence and adverse consequences of seizure linked with MSD.

OBJECTIF: Déterminer le risque spécifique de convulsions chez les enfants de moins de cinq ans hospitalisés pour une diarrhée modérée à sévère (DMS) en milieu rural. MÉTHODE: Il s'agissait d'une étude prospective cas-témoins avec suivi, menée dans un établissement sentinelle de l'Etude Globale Multicentrique Entérique à Mirzapur, une communauté rurale du Bangladesh entre 2007 et 2010. Les enfants âgés de 0 à 59 mois qui se sont présentés avec une DMS et des convulsions constituaient les cas, tandis que ceux qui n'avaient pas des convulsions constituaient les témoins. La DMS a été définie si les épisodes étaient associés à une déshydratation ou à une dysenterie ou nécessitaient une hospitalisation pour diarrhée ou dysenterie. Tous les enfants recrutés ont été suivis à domicile dans les 50 à 90 jours suivant le recrutement. Un total de 64 cas et 128 témoins sélectionnés au hasard ont constitué l'ensemble de données analysables. RÉSULTATS: Le résultat de l'analyse de régression logistique après ajustement des facteurs de confusion potentiels a révélé que la shigellose (espèce Shigella, OR = 5,34 ; IC95%: 2,37-12,04) en particulier S. flexneri (OR = 3,34 ; IC95%: 1,48-7,57), S. flexneri 6 (OR = 23,24 ; IC95%: 2.79-193,85), S. sonnei (OR = 6,90 ; IC95%: 2,34-19,85) ; les norovirus (OR = 6,77 ; IC95%: 1,69-27,11), la fièvre (OR = 16,75 ; IC95%: 1,81-154,70) et la perte de conscience (OR = 35,25 ; IC95%: 1,71-726,20) étaient les facteurs de risque indépendants de convulsions chez les enfants souffrant de DMS. Lors du recrutement, les cas avaient un score Z poids pour la taille (ZPT) plus faible (P = 0,006) que leurs pairs, les anthropométries de suivi ont montré une amélioration significative du ZPT (P < 0,001) et du score Z poids pour l'âge (P < 0,05); tandis que le score Z taille pour l'âge (p < 0,001) s'est détérioré chez cas et chez les témoins. CONCLUSION: Les épisodes de DMS de l'enfance, notamment due à Shigella et aux norovirus, sont souvent associés à des convulsions. L'identification rapide et la prise en charge appropriée des enfants atteints de shigellose peuvent réduire la survenue et les conséquences négatives des crises liées aux DMS.

Diarrhoeal children with concurrent severe wasting and stunting compared to severe wasting or severe stunting.

OBJECTIVE: Children with both severe wasting and severe stunting (SWSS) represent an extreme form of malnutrition and are prone to develop severe infection. The study aims to demonstrate clinical features and aetiology of diarrhoea among children with SWSS compared to those with either severe wasting (SW) or severe stunting (SS), which may help in early identification of high-risk children. METHODS: Data were extracted from the database of the diarrhoeal disease surveillance system (DDSS) of Dhaka Hospital, icddr,b from 2008 to 2017. Among 14 403 under-five diarrhoeal children, 149 had concurrent SWSS (WLZ/WHZ ˂-3 with LAZ/HAZ ˂-3), 795 had SW (WLZ/WHZ ˂-3 but LAZ/HAZ ≥-3) alone, and 1000 had only SS (LAZ/HAZ ˂-3 but WLZ/WHZ ≥-3). RESULTS: In logistic regression analysis after adjusting for potential confounders, dehydrating diarrhoea and slum dwelling were independently associated with SWSS vs. SW (P < 0.05). When compared with SS, dehydration and maternal illiteracy were independently associated with SWSS (P < 0.05). In comparison with SW or SS, SWSS less often included infection with rotavirus (P < 0.05). Dehydration was independently associated with SW vs. SS after adjusting for potential confounders (P < 0.05). CONCLUSION: Children with SWSS more often presented with dehydrating diarrhoea (69%) than children who had either SW (55%) or SS (43%). However, SWSS patients less frequently presented with rotavirus-associated diarrhoeal illnesses. This result underscores the importance of early detection and prompt management of dehydrating diarrhoea in children with concomitant severe wasting and severe stunting to reduce morbidity and mortality in these children, especially in poor settings.

OBJECTIF: Les enfants souffrant à la fois d'émaciation sévère et de retard de croissance sévère (ESRCS) représentent une forme extrême de malnutrition et sont susceptibles de développer des infections graves. L'étude vise à démontrer les caractéristiques cliniques et l'étiologie de la diarrhée chez les enfants atteints d'ESRCS par rapport à ceux souffrant d'émaciation sévère ou de retard de croissance sévère, ce qui pourrait aider à identifier rapidement les enfants à haut risque. MÉTHODES: Les données ont été extraites de la base de données du système de surveillance des maladies diarrhéiques (SSMD) de l'hôpital de Dhaka, icddr,b de 2008 à 2017. Parmi les 14.403 enfants de moins de cinq ans atteints de diarrhée, 149 avaient une ESRCS concomitants (WLZ/WHZ ˂-3 avec LAZ/HAZ ˂-3), 795 avaient une ES seule (WLZ/WHZ ˂-3 mais LAZ/HAZ ≥-3) et 1000 avaient un RCS seul (LAZ/HAZ ˂-3 mais WLZ/WHZ ≥-3). RÉSULTATS: Dans l'analyse de régression logistique, après ajustement des facteurs de confusion potentiels, la diarrhée déshydratante et l'habitation dans les bidonvilles étaient associées indépendamment à l'ESRCS par rapport à l'ES (P < 0,05). Par rapport au RCS, la déshydratation et l'analphabétisme de la mère ont été associés indépendamment à l'ESRCS (P < 0,05). Par rapport à l'ES ou au RCS, l'ESRCS incluait moins souvent l'infection par un rotavirus (P < 0,05). La déshydratation a été associée indépendamment à l'ES comparé au RCS après ajustement pour les facteurs de confusion potentiels (P < 0,05). CONCLUSION: Les enfants ayant une ESRCS présentent plus souvent une diarrhée déshydratante (69%) que ceux ayant soit une ES (55%) ou un RCS (43%). Cependant, les enfants atteints d'ESRCS présentaient moins fréquemment des maladies diarrhéiques associées à un rotavirus. Ce résultat souligne l'importance d'une détection précoce et d'une prise en charge rapide de la diarrhée déshydratante chez les enfants présentant une émaciation et un retard de croissance sévères concomitants, afin de réduire la morbidité et la mortalité chez ces enfants, en particulier dans les milieux pauvres.

Changing Susceptibility Pattern of Vibrio cholerae O1 Isolates to Commonly Used Antibiotics in the Largest Diarrheal Disease Hospital in Bangladesh during 2000-2018.

The efficacy of commonly used antibiotics for treating severe cholera has been compromised over time because of the reduced antibiotic susceptibility. This study aimed to describe the rate of detection of Vibrio cholerae O1 from fecal samples and antimicrobial susceptibility profiles of V. cholerae O1 serotypes to commonly used antibiotics. During January 2000-December 2018, V. cholerae O1 was detected in fecal samples of 7,472 patients. Vibrio cholerae O1 Inaba serotype was predominant, ranging from 60% to 86% during the period 2000-2006 except for 2003 and 2005 when the Ogawa serotype was predominant. Later on, the Ogawa serotype became predominant from 2007 to 2015, fluctuating between 52% and 100%. However, in 2016 and 2017, isolation rates declined to 2% and 1%, respectively, but surged again to 75% in 2018. Nearly 100% of V. cholerae O1 strains were sensitive to tetracycline during 2000-2004. Thereafter, a declining trend of sensitivity was observed to be continued and dropped down to < 6% during 2012-2017 and again increased to 76% in 2018. Susceptibility to azithromycin and ciprofloxacin was nearly 100%, and susceptibility to cotrimoxazole and furazolidone was 01% throughout the study period. We also found the emergence of resistance to erythromycin in 2005 and sensitivity to cotrimoxazole in 2018. Thus, the rapid decline of the sensitivity of V. cholerae O1 to tetracycline and a reversed peak after 6 years need continued monitoring and reporting.

Viral Pathogen-Specific Clinical and Demographic Characteristics of Children with Moderate-to-Severe Diarrhea in Rural Bangladesh.

Diarrheal disease is a leading cause of childhood morbidity and mortality worldwide, but particularly in low-income countries in sub-Saharan Africa and South Asia. The Global Enteric Multicenter Study (GEMS) examined the infectious etiologies as well as associated demographics, socioeconomic markers, health-care-seeking behaviors, and handwashing practices of the households of children with diarrhea and their age- and gender-matched controls in seven countries over a 3-year period (December 2007-December 2010). Stool studies to determine diarrheal etiologies and anthropometry were performed at baseline and at 60-day follow-up visits, along with surveys to record demographics and living conditions of the children. We performed secondary analyses of the GEMS data derived from the Bangladesh portion of the study in children with diarrhea associated with viral enteropathogens and explored pathogen-specific features of disease burden. Rotavirus and norovirus were the most prevalent pathogens (39.3% and 35%, respectively). Disease due to rotavirus and adenovirus was more common in infants than in older children (P < 0.001 and P = 0.001, respectively). Height for age decreased from baseline to follow-up in children with diarrhea associated with rotavirus, norovirus, and adenovirus (P < 0.001). Based on these analyses, preventive measures targeted at rotavirus, norovirus, and adenovirus will be expected to have meaningful clinical impact. Cost of treatment was highest for rotavirus as well, making it an obvious target for intervention. Association of specific viruses with stunting is particularly notable, as stunting is an attributable risk factor for poor cognitive development and future productivity and economic potential.

Health care-seeking behavior for childhood diarrhea in Mirzapur, rural Bangladesh.

We evaluated patterns of health care use for diarrhea among children 0-59 months of age residing in Mirzapur, Bangladesh, using a baseline survey conducted during May-June 2007 to inform the design of a planned diarrheal etiology case/control study. Caretakers of 7.4% of 1,128 children reported a diarrheal illness in the preceding 14 days; among 95 children with diarrhea, 24.2% had blood in the stool, 12.2% received oral rehydration solution, 27.6% received homemade fluids, and none received zinc at home. Caretakers of 87.9% sought care outside the home; 49.9% from a pharmacy, and 22.1% from a hospital or health center. The primary reasons for not seeking care were maternal perception that the illness was not serious enough (74.0%) and the high cost of treatment (21.9%). To improve management of childhood diarrhea in Mirzapur, Bangladesh, it will be important to address knowledge gaps in caretakers' assessment of illness severity, appropriate home management, and when to seek care in the formal sector. In addition, consideration should be given to inclusion of the diverse care-giving settings in clinical training activities for diarrheal disease management.