Outbreak of seafood-related food poisoning from undetectable Vibrio parahaemolyticus-like pathogen, Chiang Mai Province, Thailand, December 2020.

OBJECTIVE: On 1 December 2020, the Department of Disease Control of Thailand was notified of a cluster of food poisoning cases among participants at a church festival in Mae Ai district, Chiang Mai province. We conducted an outbreak investigation to confirm diagnosis, describe the epidemiological characteristics of the outbreak, identify possible sources of the outbreak and provide appropriate control measures. METHODS: We reviewed medical records of the food poisoning cases from the health care centres. Active case finding was conducted among participants who had consumed food and water at the festival. An environmental survey was done in the village where the festival was held. A case-control study was conducted to identify the source of the outbreak. Samples for laboratory analysis included rectal swabs and fresh stool specimens from the cases and food handlers, surface swabs of cooking equipment, food, water and ice samples. RESULTS: Among 436 participants surveyed, 368 (84.4%) cases of food poisoning were identified. The most common clinical manifestation was abdominal pain (89.7%), followed by watery diarrhoea (45.7%), nausea (43.5%), vomiting (38.9%), fever (18.5%) and bloody diarrhoea (4.6%). None died in this outbreak. The case-control study showed that mixed spicy seafood salad served in the festival was significantly associated with the disease by both univariable and multivariable analyses. However, the causative agent could not be identified. The environmental investigation suggested this seafood might have been undercooked. CONCLUSION: Clinical manifestations of the cases, incubation period and the suspected seafood salad suggested seafood-related food poisoning. Grimontia hollisae, the organism causing illness similar to Vibrio parahaemolyticus and commonly undetectable in the laboratory with routine testing, might be the pathogen that caused this outbreak. G. hollisae should be in differential diagnosis and identified in seafood-associated outbreaks.

Increased platelet activation in subjects chronically exposed to cadmium: A pilot study.

Cadmium exposure has been reported to be associated with the risk of vascular disorders. Here, we investigated platelet activity in subjects with chronic cadmium exposure. Eighteen and 15 women participated in this study as chronically cadmium-exposed and control non-exposed subjects, respectively. Plasma P-selectin and CD40 ligand (CD40L), soluble markers of platelet activation, were measured. Platelet aggregation in whole blood, P-selectin and activated glycoprotein (aGP) IIb/IIIa expression on platelets and platelet-leukocyte aggregates were determined. The levels of plasma P-selectin and CD40L increased in subjects with chronic cadmium exposure compared with control subjects. Platelet aggregation induced by adenosine diphosphate (ADP) was higher in cadmium-exposed subjects than control subjects. Cadmium-exposed subjects had higher baseline and ADP-induced aGPIIb/IIIa expression on platelets than control subjects. Platelet-neutrophil aggregates also increased in cadmium-exposed subjects. Blood cadmium correlated with ADP-induced aggregation, aGPIIb/IIIa expression and platelet-neutrophil aggregates, while urinary cadmium correlated with soluble P-selectin. However, cadmium only at high concentration (15 µM) could potentiate ADP-induced platelet activation in vitro. In conclusion, our pilot data show that cadmium-exposed subjects have increased baseline platelet activation and reactivity.

Renal and blood pressure effects from environmental cadmium exposure in Thai children.

Very few studies have shown renal and blood pressure effects from environmental cadmium exposure in children. This population study examined associations between urinary cadmium excretion, a good biomarker of long-term cadmium exposure, and renal dysfunctions and blood pressure in environmentally exposed Thai children. Renal functions including urinary excretion of ß2-microglobulin, calcium (early renal effects), and total protein (late renal effect), and blood pressure were measured in 594 primary school children. Of the children studied, 19.0% had urinary cadmium ≥ 1 µg/g creatinine. The prevalence of urinary cadmium ≥ 1 µg/g creatinine was significantly higher in girls and in those consuming rice grown in cadmium-contaminated areas. The geometric mean levels of urinary ß2-microglobulin, calcium, and total protein significantly increased with increasing tertiles of urinary cadmium. The analysis did not show increased blood pressure with increasing tertiles of urinary cadmium. After adjusting for age, sex, and blood lead levels, the analysis showed significant positive associations between urinary cadmium and urinary ß2-microglobulin and urinary calcium, but not urinary total protein nor blood pressure. Our findings provide evidence that environmental cadmium exposure can affect renal functions in children. A follow-up study is essential to assess the clinical significance and progress of renal effects in these children.

HUMAN HEALTH EFFECTS FROM CADMIUM EXPOSURE: COMPARISON BETWEEN PERSONS LIVING IN CADMIUM-CONTAMINATED AND NON-CONTAMINATED AREAS IN NORTHWESTERN THAILAND.

Environmental cadmium contamination is present in some rural villages of Mae Sot District, Tak Province, northwestern Thailand. We compared the health of 751 persons aged ≥ 35 years living in 3 contaminated villages with 682 people from 3 non-contaminated villages with similar socio-demographic and lifestyle characteristics in the same district. All the subjects were screened for urinary cadmium (a biomarker for long-term cadmium exposure), renal function, hypertension, diabetes, hypercholesterolemia, hypertriglyceridemia, urinary tract stone disease and bone mineral density in 2012. The study renal functions included urinary excretion of ß2-microglobulin (early tubular effect), total urine protein and glomerular filtration rate (glomerular effects). The geometric mean of urinary cadmium level was significantly higher among persons living in the contaminated areas (2.96 µg/g creatinine) than those in the non-contaminated areas (0.60 µg/g creatinine). Persons living in contaminated areas had a significantly higher prevalence of renal dysfunction, bone mineral loss, hypertension and urinary stones than those living in non-contaminated areas. There were no significant differences between the 2 groups in the prevalence of diabetes, hypercholesterolemia and hypertriglyceridemia. This study shows health effects due to environmental cadmium exposure. The prevalences of diabetes, hypercholesterolemia, and hypertriglyceridemia were not associated with cadmium exposure.

Risk assessment for Thai population: benchmark dose of urinary and blood cadmium levels for renal effects by hybrid approach of inhabitants living in polluted and non-polluted areas in Thailand.

BACKGROUND: The aim of the present study was to estimate the benchmark doses (BMD) for renal effects for health risk assessment of residents living in Cd-polluted and non-polluted areas in a Thai population. METHODS: The study participants consisted of inhabitants aged 40 years or older who lived in a non-polluted area (40 men and 41 women) and in the environmentally polluted Mae Sot District (230 men and 370 women) located in northwestern Thailand. We measured urinary and blood cadmium (Cd) as markers of long-term exposure and urinary ß2-microglobulin (ß2-MG) and N-acetyl-ß-D-glucosaminidase (NAG) as renal tubular effect markers. An updated hybrid approach was applied to estimate the benchmark doses (BMD) and their 95% lower confidence limits (BMDL) of urinary and blood Cd for Cd-induced renal effects in these subjects. BMD and BMDL corresponding to an additional risk (BMR) of 5% were calculated with the background risk at zero exposure set to 5% after adjusting for age and smoking status. RESULTS: The estimated BMDLs of urinary Cd for renal effect markers were 6.9 for urinary ß2-MG and 4.4 for NAG in men and 8.1 for ß2-MG and 6.1 for NAG µg/g creatinine (Creat) in women. These BMDLs of urinary Cd (µg/g Creat) for NAG were less than the geometric mean urinary Cd in the polluted area (6.5 in men and 7.1 in women). The estimated BMDLs of blood Cd (µg/L) were 6.2 for urinary ß2-MG and 5.0 for NAG in men and 5.9 for ß2-MG and 5.8 for NAG in women. The calculated BMDLs were similar or less compared with the geometric mean blood Cd (µg/L) in the polluted Thai area (6.9 in men and 5.2 in women). CONCLUSION: The BMDLs of urinary and blood Cd for renal effects were estimated to be 4.4-8.1 µg/g Creat and 4.4-6.2 µg/L in the Thai population aged ≥ 40 years old, suggesting that more than 40% of the residents were at risk of adverse renal effects induced by Cd exposure in Thailand.

PERSONAL AND ENVIRONMENTAL RISK FACTORS SIGNIFICANTLY ASSOCIATED WITH ELEVATED BLOOD LEAD LEVELS IN RURAL THAI CHILDREN.

A community-based study was conducted to determine personal risk factors and environmental sources of lead exposure for elevated blood lead levels (≥ 10 µg/dl, EBLLs) among rural children living at the Thailand-Myanmar border in Tak Province, northwestern Thailand. Six hundred ninety-five children aged 1-14 years old were screened for BLLs. Environmental specimens for lead measurements included samples of water from the streams, taps, and household containers, house floor dust, and foods. Possible lead release from the cooking ware was determined using the leaching method with acetic acid. The overall prevalence of EBLLs was 47.1% and the geometric mean level of blood lead was 9.16 µg/dl. Personal risk factors significantly associated with EBLLs included being male, younger age, anemia, and low weight-for-age. Significant environmental risk factors were exposure to a lead-acid battery of solar energy system and use of a non-certified metal cooking pot. Some families whose children had high BLLs reported production of lead bullets from the used batteries at home. About one-third of the house dust samples taken near batteries contained lead content above the recommended value, compared with none of those taken from other areas and from the houses with no batteries. The metal pots were safe for cooking rice but might be unsafe for acidic food preparation. Both nutritional intervention and lead exposure prevention programs are essential to reduce EBLLs in this population.

Blood lead levels among rural Thai children exposed to lead-acid batteries from solar energy conversion systems.

We evaluate blood lead levels among Thai children to determine if exposure to lead-acid batteries is associated with elevated blood lead levels (EBLL). We screened 254 children aged 1-14 years old from 2 rural Thai villages for blood lead levels. We also screened 18 of 92 houses in these 2 villages for the presence of environmental lead. The overall prevalence of EBLL (> or = 10 microg/dl) was 43.3% and the mean lead level among study subjects was 9.8 +/- 5.1 microg/dl. The blood lead levels significantly decreased with increasing age. Fifty point eight percent of children who lived in a house with vented lead-acid batteries had EBLL while 23.3% of children who lived in a house without vented lead-acid batteries had EBLL. Multiple logistic regression analysis revealed a significant positive association between the presence of vented lead-acid batteries and EBLL, after adjusting for other variables. Forty-two point nine percent of house floor dust samples collected near the batteries had elevated lead levels, 7.1% of house floor dust samples collected from other areas in the house had elevated lead levels and 0% of the house floor dust samples collected in houses without vented lead-acid batteries had elevated lead levels. In the sampled houses with vented lead-acid batteries, lead contamination was found in the drinking-water kept in household containers, but not in the tap water or other village sources of water. Improper care and placement of vented lead-acid batteries can result in lead contamination in the home environment causing EBLL in exposed children.

Field evaluation of a simple fluorescence method for detection of viable Mycobacterium tuberculosis in sputum specimens during treatment follow-up.

Simple tuberculosis (TB) treatment monitoring tools are needed. We assessed the performance of fluorescein-diacetate (FDA) smear microscopy for detection of viable Mycobacterium tuberculosis in sputum specimens (n = 288) of TB cases under treatment compared to culture (17.4% culture positivity). FDA sensitivity was moderate (83.7% [95% confidence interval {CI}, 70.3 to 92.6]), and specificity was low (66.1% [59.5 to 72.2]). The good negative predictive value (94.8% [90.1 to 97.8]) and negative likelihood ratio (0.2) suggest using this method to rule out treatment failure in settings without access to culture.

Progress in cadmium-related health effects in persons with high environmental exposure in northwestern Thailand: a five-year follow-up.

Food-borne cadmium was the principal source of exposure for persons living in the 12 cadmium-contaminated villages in Mae Sot District, Tak Province, northwestern Thailand. This report presents progress in cadmium-related health effects among persons with high cadmium exposure. The study included 436 persons who had urinary cadmium levels ≥5 µg/g creatinine and were screened for urinary cadmium, renal function, hypertension, diabetes and urinary stones in 2005 (baseline) and 2010 (5-year follow-up). Study renal biomarkers included urinary excretion of ß(2)-microglobulin (ß(2)-MG), total protein and calcium, serum creatinine and glomerular filtration rate (GFR). The geometric mean level of urinary cadmium statistically significantly reduced from 9.5±1.6 µg/g creatinine in 2005 to 8.8±1.6 µg/g creatinine in 2010. Compared to baseline, the follow-up examination revealed significant increases in urinary ß(2)-MG (tubular effect), urinary total protein and serum creatinine, and a decrease in GFR (glomerular effects). Progressive renal dysfunctions were similarly observed in persons both with and without reduction in cadmium intake. Significant increases in prevalence of hypertension, diabetes and urinary stones were also detected at follow-up. These three disorders were found to markedly impair renal functions in the study persons. Our study indicates that in persons with prolonged excessive cadmium exposure, toxic health effects may progress even after exposure reduction. Renal damage from cadmium can be due to its direct nephrotoxic effect and also through the related disorders causing nephropathy.

Two consecutive outbreaks of food-borne cholera associated with consumption of chicken rice in northwestern Thailand.

Hainanese chicken rice (cooked rice mixed with chicken fat and served with sliced chicken and cucumber) is a well-known Chinese dish in Southeast Asian countries. We report two consecutive outbreaks of cholera associated with consumption of chicken rice among attendants of two meetings in northwestern Thailand in April 2010. Active case finding was carried out among persons who attended the meetings and in the community. Environmental investigation was conducted at the implicated food shop and in the affected areas. The first outbreak involved 17 cholera cases (35.4%) among 48 attendants and 16 cases in the community. The onset of symptoms was between April 19 and 23, 2010. People who ate the chicken rice had a higher attack rate of infection than those who did not. All 12 food handlers at the implicated food shop were screened for cholera infection by rectal swab culture; 3 were culture-positive. Although the food shop was closed temporarily following the outbreak, some chicken rice was produced and served at the second meeting and caused 11 more cases (23.4%) among 47 meeting attendants. All cholera isolates obtained from patients and food handlers were V. cholerae O1, biotype El Tor, serotype Ogawa, and had similar antibiograms and genetic patterns by pulsed-field gel electrophoresis. The chicken rice which was possibly contaminated by an infected food handler served as the vehicle of transmission. A repeat cholera outbreak caused by the same vehicle can occur when control measures are not adequately followed.

An association between urinary cadmium and urinary stone disease in persons living in cadmium-contaminated villages in northwestern Thailand: a population study.

Excessive urinary calcium excretion is the major risk of urinary stone formation. Very few population studies have been performed to determine the relationship between environmental cadmium exposure and urinary stone disease. This population-based study examined an association between urinary cadmium excretion, a good biomarker of long-term cadmium exposure, and prevalence of urinary stones in persons aged 15 years and older, who lived in the 12 cadmium-contaminated villages in the Mae Sot District, Tak Province, northwestern Thailand. A total of 6748 persons were interviewed and screened for urinary cadmium and urinary stone disease in 2009. To test a correlation between urinary excretion of cadmium and calcium, we measured urinary calcium content in 1492 persons, who lived in 3 villages randomly selected from the 12 contaminated villages. The rate of urinary stones significantly increased from 4.3% among persons in the lowest quartile of urinary cadmium to 11.3% in the highest quartile. An increase in stone prevalence with increasing urinary cadmium levels was similarly observed in both genders. Multiple logistic regression analysis revealed a positive association between urinary cadmium levels and stone prevalence, after adjusting for other co-variables. The urinary calcium excretion significantly increased with increasing urinary cadmium levels in both genders, after adjusting for other co-variables. Elevated calciuria induced by cadmium might increase the risk of urinary stone formation in this environmentally exposed population.

Correlations of urinary cadmium with hypertension and diabetes in persons living in cadmium-contaminated villages in northwestern Thailand: A population study.

Risk for hypertension and diabetes has not been conclusively found to be a result of cadmium exposure. A population-based study was conducted in 2009 to examine the correlations of urinary cadmium, a good biomarker of long-term cadmium exposure, with hypertension and diabetes in persons aged 35 years and older who lived in the 12 cadmium-contaminated rural villages in northwestern Thailand. A total of 5273 persons were interviewed and screened for urinary cadmium, hypertension, and diabetes. The geometric mean level of urinary cadmium for women (2.4+/-2.3 microg/g creatinine) was significantly greater than that for men (2.0+/-2.2 microg/g creatinine). Hypertension was presented in 29.8% of the study population and diabetes was detected in 6.6%. The prevalence of hypertension significantly increased from 25.0% among persons in the lowest tertile of urinary cadmium to 35.0% in the highest tertile. In women, the rate of hypertension significantly increased with increasing urinary cadmium levels in both ever and never smokers, after adjusting for age, alcohol consumption, body mass index, and diabetes. In men, such association was less significantly found in never smokers. The study revealed no significant association between urinary cadmium and diabetes in either gender. Our study supports the hypothesis that environmental exposure to cadmium may increase the risk of hypertension. Risk for diabetes in relation to cadmium exposure remains uncertain in this exposed population.

Bone resorption acceleration and calcium reabsorption impairment in a Thai population with high cadmium exposure.

Some residents of the Mae Sot district in Thailand have suffered long-term exposure to elevated dietary levels of cadmium. To test the hypothesis that chronic dietary cadmium exposure can cause imbalance in calcium dynamics and accelerate bone resorption, a group of these residents (156 men and 256 women aged >/= 50) were selected on the basis of previous records of elevated urinary cadmium and tested for urinary and blood cadmium, bone formation and resorption markers, and the renal tubular dysfunction markers. Both genders had high levels of blood and urinary cadmium and high urinary levels of the markers for renal dysfunction and bone resorption in a dose-response relationship to urinary cadmium. The excretion of bone resorption markers was positively correlated to the ratio of excreted calcium and urinary cadmium. The results of a multivariate regression analysis indicated that bone resorption was accelerated by impaired calcium reabsorption in renal tubules.

A case of nosocomial cholera during a community outbreak in a Thai-Myanmar border area.

The present study presents a case of nosocomial cholera in one general hospital located in a Thai-Myanmar border area. Between May and October 2007, a community outbreak of cholera with 477 cases took place in Mae Sot District, Tak Province. A 71-year-old diabetic female who had undergone craniotomy following intracerebral hemorrhage contracted nosocomial cholera with mild diarrhea on August 6, 2007, 37 days after admission in a female ward of the Mae Sot hospital. She received a nasogastric tube-fed diet four times a day. The investigation suggested that the tube-fed diet might have been contaminated with V. cholerae O1 directly from an infected caretaker. This caretaker was culture-positive for cholera of the same biotype, serotype, and antibiograms. The present report indicates that during a community outbreak of cholera, nosocomial infection can occur in the hospital. Thus, a program of nosocomial infection control is essential in the hospital.

Changes in cadmium exposure among persons living in cadmium-contaminated areas in northwestern Thailand: a five-year follow-up.

OBJECTIVE: To determine changes in cadmium exposure among persons aged 15 years and older who lived in the 12 cadmium-contaminated villages in northwestern Thailand. MATERIAL AND METHOD: Urinary cadmium was measured among villagers in 2004. An exposure reduction campaign was conducted soon afterwards, and in 2009, urinary cadmium was measured among people living in the same villages. The survey participants were asked about their smoking status and consumption of rice grown locally in cadmium-contaminated areas. Both were the two main routes of cadmium exposure in these villages. RESULTS: Seven thousand six hundred ninety seven and 6748 persons participated in the first and second surveys, respectively. The proportion of current smokers was higher in the first survey (34.9%) than the second survey (31.5%). The proportion of persons who consumed rice grown locally decreased from 88.0% in the first survey to 50.5% in the second survey. Of persons who consumed rice grown locally, the proportion of those with urinary cadmium > or =2 microg/g creatinine increased from 55.5% in the first survey to 61.3% in the second survey. Of persons consuming rice purchased from other areas, the proportion of those with urinary cadmium > or =2 microg/g creatinine decreased from 46.7% in the first survey to 35.6% in the second survey. In both surveys, the adjusted odds ratio for increasing prevalence of high urinary cadmium associated with consumption of locally grown rice was greater than that for tobacco smoking. CONCLUSION: Urinary excretion of cadmium significantly decreased after environmental cadmium exposure was reduced.

Lack of safety systems in agricultural settings in rural Thailand: a report of three worker death.

BACKGROUND: Three farm workers lost consciousness within a few minutes after entering a silo pit on a farm located in a rural Thai village. All victims died later in the hospital. OBJECTIVE: To identify the cause of unconsciousness in these victims and to determine safety systems for agricultural enterprises containing silos. MATERIAL AND METHOD: Medical records of the three decedents were reviewed for demographic characteristics, clinical manifestations, and the cause of deaths. Co-workers of the decedents were interviewed to obtain details of the victims' work on the farm during the incident. Concentrations of oxygen and other potentially hazardous gases were measured in the pit where the victims collapsed. All agricultural enterprises that have silos in the district were identified and investigated for safety systems. RESULTS: Of the three decedents, two died in a rescue attempt. They all developed metabolic acidosis and died 1-3 days following admission. Oxygen concentration at the top of the pit was 20.9% and decreased to 0.8% at a depth of 1 meter and to 0.0% at the bottom of the three-meter pit. Carbon dioxide, which is heavier than air, was the major asphyxiant displacing oxygen in this confined space. Lack of safety systems were detected on this farm and in all settings containing silos in the district. CONCLUSION: Asphyxiation due to oxygen depletion was the cause of all deaths. It is essential to install safety systems for work in confined spaces in agricultural settings.

Cadmium-exposed population in Mae Sot District, Tak Province: 4 bone mineral density in persons with high cadmium exposure.

OBJECTIVE: To measure bone mineral density in cadmium-exposed persons aged 40 years and older that lived in the 12 contaminated villages in northwestern Thailand. MATERIAL AND METHOD: Five hundred seventy three persons with urinary cadmium levels > or = 5 microg/g creatinine during the 2004-2006 surveys were screened in 2007 for urinary excretion of cadmium, bone formation and resorption markers, and renalfunction markers. Calcaneus bone density was measured in each person by a dual-energy X-ray absorptiometry bone scanner. RESULTS: The mean age of the study persons was 57 years old. The geometric mean level of urinary cadmium for women was significantly higher than that for men. Women had a lower mean of calcaneus bone density than men. The rate of osteoporosis in women (21.5%) was significantly higher than that for men (14.7%). Calcaneus bone density was negatively correlated with urinary excretion of calcium (in both genders) and crosslinked N-telopeptide of type I collagen (in women), after adjusting for other co-variables. Increasing urinary cadmium levels appeared to correlate with reduced bone density in women, but not in men. In both genders, urinary excretion of beta2-microglobulin and N-acetyl-beta-D-glucosaminidase was higher in persons with osteoporosis than those without. CONCLUSION: Bone mineral loss is correlated with urinary cadmium levels and renal dysfunction in this female population.

Cadmium-exposed population in Mae Sot district, Tak province: 3. Associations between urinary cadmium and renal dysfunction, hypertension, diabetes, and urinary stones.

OBJECTIVE: To study the associations between urinary cadmium and renal dysfunction, hypertension, diabetes, and urinary stones in an adult population living in cadmium-contaminated areas in Mae Sot District, Tak Province, Thailand. MATERIAL AND METHOD: Seven hundred ninety five cadmium-exposed adults were screened for urinary cadmium, renal dysfunction, hypertension, diabetes, and urinary stones in 2005. Six selected markers of renal function in the present study were urinary excretion of beta2-microglobulin (beta2-MG), N-acetyl-beta-D-glucosaminidase (NAG), total protein and calcium, serum creatinine, and glomerular filtration rate (GFR). RESULTS: The mean age of the study persons was 50-years-old. The overall prevalence rates of hypertension, diabetes, and urinary stones were 33.3%, 6.2%, and 8.9% respectively. The prevalence of increased proteinuria was greatest in those with urinary cadmium levels > or = 15 microg/g creatinine. Urinary excretion of beta2-MG, NAG, and total protein significantly increased with increasing urinary cadmium levels, after adjusting for other co-variables by multiple linear regression analysis. However, urinary cadmium was not significantly associated with urinary calcium, serum creatinine, and GFR. The prevalence rates of hypertension, diabetes, and urinary stones did not significantly increase with increasing urinary cadmium levels. Hypertension, diabetes, and urinary stones were also significant predictors of impaired renal function. CONCLUSION: In this population, increasing levels of urinary cadmium are associated with increasing urinary excretion of beta2-MG, NAG, and total protein. Risk for hypertension, diabetes, and urinary stones remains uncertain in relation to cadmium exposure.

Evaluation of Immunization Services for Children of Migrant Workers Along Thailand-Myanmar Border: Compliance with Global Vaccine Action Plan (2011-2020).

Immunization is a core component of the human right to health. However, accessibility to the Expanded Program on Immunization (EPI) might be difficult among migrant children. This study aims to assess the vaccination coverage of migrant children under a mobile immunization program, initiated by the Thai government in 2014. A cross-sectional, mixed-methods study was conducted in five districts along the Thailand-Myanmar border during July-December 2018. The immunization history during their first year of life was obtained. Focus group discussions were conducted among stakeholders to explore their satisfaction toward the immunization service. Mothers/guardians of 1707 migrant children participated in the survey, with a 71% response rate. The vaccination coverage increased during 2014-2017. The highest vaccination coverage was observed for Bacillus CalmetteGuérin vaccine, with 83.2% coverage in 2017. The vaccination coverage of three doses of diphtheriatetanuspertussis vaccine and Hepatitis B vaccine and oral polio vaccine increased from 34.8% in 2014 to 56.3% in 2017. For measles-containing vaccine, the vaccination coverage increased from 32.4% in 2014 to 54.6% in 2017. Overall, all stakeholders were satisfied with the immunization service. Increased workload and communication barriers were the main factors that influenced the satisfaction toward the immunization program.

Etiologic features of diarrheagenic microbes in stool specimens from patients with acute diarrhea in Thailand.

Many microbial species have been recognized as enteropathogens for humans. Here, we predicted the causative agents of acute diarrhea using data from multiplex quantitative PCR (qPCR) assays targeting 19 enteropathogens. For this, a case-control study was conducted at eight hospitals in Thailand. Stool samples and clinical data were collected from 370 hospitalized patients with acute diarrhea and 370 non-diarrheal controls. Multiple enteropathogens were detected in 75.7% and 13.0% of diarrheal stool samples using multiplex qPCR and bacterial culture methods, respectively. Asymptomatic carriers of enteropathogens were found among 87.8% and 45.7% of individuals by qPCR and culture methods, respectively. These results suggested the complexity of identifying causative agents of diarrhea. An analysis using the quantification cut-off values for clinical relevance drastically reduced pathogen-positive stool samples in control subjects from 87.8% to 0.5%, whereas 48.9% of the diarrheal stool samples were positive for any of the 11 pathogens. Among others, rotavirus, norovirus GII, Shigella/EIEC, and Campylobacter were strongly associated with acute diarrhea (P-value < 0.001). Characteristic clinical symptoms, epidemic periods, and age-related susceptibility to infection were observed for some enteropathogens. Investigations based on qPCR approaches covering a broad array of enteropathogens might thus improve our understanding of diarrheal disease etiology and epidemiological trends.