The complex association between drinking water consumption and endemic gastrointestinal illness as shown by Swedish cohort studies.

It is well known that municipal drinking water may be the cause of gastrointestinal illness (GII) outbreaks, but it is still unclear to what extent drinking water contributes to endemic GII. To explore this, we conducted a prospective cohort study among 6,955 adults in five municipalities in Sweden, collecting monthly GII episodes and mean daily cold drinking water consumption through SMS (Short Message Service). When the association between drinking water consumption and GII (all symptoms) and acute gastrointestinal illness (AGI, vomiting and/or three loose stools during a 24-h period) were assessed, there were indications that the association departed from linearity, following a unimodal shape. Among consumers in surface water areas, the highest risk of GII and AGI was generally seen among the average consumers, while the opposite was seen among groundwater consumers. The association however also seemed to be affected by neighbouring communities. The results of the study indicate that there is indeed an association between drinking water consumption and endemic GII, but the nature of this association is complex and likely affected by multiple factors, for example, water source type in the home and degree of exposure to drinking water from additional sources.

Two risk assessments: Evaluating the use of indicator HF183 Bacteroides versus pathogen measurements for modelling recreational illness risks in an urban watershed.

The purpose of this study was to evaluate the performance of HF183 Bacteroides for estimating pathogen exposures during recreational water activities. We compared the use of Bacteroides-based exposure assessment to exposure assessment that relied on pathogen measurements. We considered two types of recreational water sites: those impacted by combined sewer overflows (CSOs) and those not impacted by CSOs. Samples from CSO-impacted and non-CSO-impacted urban creeks were analysed by quantitative polymerase chain reaction (qPCR) for HF183 Bacteroides and eight human gastrointestinal pathogens. Exposure assessment was conducted two ways for each type of site (CSO-impacted vs. non-CSO impacted): 1) by estimating pathogen concentrations from HF183 Bacteroides concentrations using published ratios of HF183 to pathogens in sewage and 2) by estimating pathogen concentrations from qPCR measurements. QMRA (quantitative microbial risk assessment) was then conducted for swimming, wading, and fishing exposures. Overall, mean risk estimates varied from 0.27 to 53 illnesses per 1,000 recreators depending on exposure assessment, site, activity, and norovirus dose-response model. HF183-based exposure assessment identified CSO-impacted sites as higher risk, and the recommended HF183 risk-based threshold of 525 genomic copies per 100 mL was generally protective of public health at the CSO-impacted sites but was not as protective at the non-CSO-impacted sites. In the context of our urban watershed, HF183-based exposure assessment over- and under-estimated risk relative to exposure assessment based on pathogen measurements, and the etiology of predicted pathogen-specific illnesses differed significantly. Across all sites, the HF183 model overestimated risk for norovirus, adenovirus, and Campylobacter jejuni, and it underestimated risk for E. coli and Cryptosporidium. To our knowledge, this study is the first to directly compare health risk estimates using HF183 and empirical pathogen measurements from the same waterways. Our work highlights the importance of site-specific hazard identification and exposure assessment to decide whether HF183 is applicable for monitoring risk.

A retrospective longitudinal study of adenovirus group F, norovirus GI and GII, rotavirus, and enterovirus nucleic acids in wastewater solids at two wastewater treatment plants: solid-liquid partitioning and relation to clinical testing data.

Enteric infections are important causes of morbidity and mortality, yet clinical surveillance is limited. Wastewater-based epidemiology (WBE) has been used to study community circulation of individual enteric viruses and panels of respiratory diseases, but there is limited work studying the concurrent circulation of a suite of important enteric viruses. A retrospective WBE study was carried out at two wastewater treatment plants located in California, United States. Using digital droplet polymerase chain reaction (PCR), we measured concentrations of human adenovirus group F, enteroviruses, norovirus genogroups I and II, and rotavirus nucleic acids in wastewater solids two times per week for 26 months (n = 459 samples) between February 2021 and mid-April 2023. A novel probe-based PCR assay was developed and validated for adenovirus. We compared viral nucleic acid concentrations to positivity rates for viral infections from clinical specimens submitted to a local clinical laboratory to assess concordance between the data sets. We detected all viral targets in wastewater solids. At both wastewater treatment plants, human adenovirus group F and norovirus GII nucleic acids were detected at the highest concentrations (median concentrations greater than 105 copies/g), while rotavirus RNA was detected at the lowest concentrations (median on the order of 103 copies/g). Rotavirus, adenovirus group F, and norovirus nucleic acid concentrations were positively associated with clinical specimen positivity rates. Concentrations of tested viral nucleic acids exhibited complex associations with SARS-CoV-2 and other respiratory viral nucleic acids in wastewater, suggesting divergent transmission patterns.IMPORTANCEThis study provides evidence for the use of wastewater solids for the sensitive detection of enteric virus targets in wastewater-based epidemiology programs aimed to better understand the spread of enteric disease at a localized, community level without limitations associated with testing many individuals. Wastewater data can inform clinical, public health, and individual decision-making aimed to reduce the transmission of enteric disease.

Physician-directed microbiological testing versus syndromic multiplex PCR in gastroenteritis.

INTRODUCTION: Syndromic multiplex PCR testing is an alternative to conventional stool testing based on physician-directed request forms. The objective of this study was to compare the etiologic yield of conventional microbiological testing based on physician-directed request forms with that of rapid syndromic testing. In addition, the adequacy of the clinician ordering, which is an important piece of the diagnostic stewardship, was evaluated. MATERIALS AND METHODS: Physician-directed conventional microbiological testing and extensive molecular syndromic testing with the Fast Track Diagnostics Gastroenteritis Kit were performed in parallel on 1238 samples to evaluate the contribution of a multiplex panel to the diagnostic process of gastroenteritis. RESULTS: A potential causative pathogen was identified in 18.4% of stool samples by standard microbiological testing and in 41.3% of stool samples tested using the syndromic panel. Only 15.1% of the request forms could be considered successful of which 88.2% were labeled inadequate. Conventional physician-directed based testing missed the etiologic diagnosis in 32.3% of the specimens (excluding sapovirus and astrovirus). Bacterial infections were theoretically not missed as bacterial stool culture was requested on all stool samples, but in 28.6% of the cases, no isolate could be recovered. In 36.9% of the samples testing positive for a viral pathogen, no viral testing was requested. In addition, 72.5% of all samples positive for a parasite were clinically suspected by the physician. CONCLUSION: This study suggests that syndromic multiplex PCR assays are a better strategy for pathogen detection in patients with gastroenteritis than physician-directed laboratory testing based on the clinical presentation.

Application of national early warning score in assessing postoperative illness severity in elderly patients with gastrointestinal illnesses.

BACKGROUND: Population aging is a social problem that is being faced in most countries. OBJECTIVE: To apply the National Early Warning Score (NEWS) for an early warning on the vital signs and consciousness of elderly patients who are hospitalized in the gastrointestinal surgical department and to provide a reference for early detection of changes in illness severity in elderly patients by studying the correlation between NEWS value and changes in illness severity. METHODS: We enrolled 528 elderly patients who were hospitalized in the gastrointestinal surgical department of a tertiary grade A hospital in Guizhou Province between June 2020 and May 2021, to analyze how NEWS max value correlates with illness severity and obtain the optimal NEWS cutoff value for both potentially critically ill and critically ill elderly patients using the receiver operating characteristic (ROC) curve. RESULTS: There were statistically significant differences in NEWS values between elderly patients with various illness severities (P< 0.05). NEWS values correlated positively with illness severity (r= 0.605, P< 0.001). Based on the ROC curve, early warning trigger values for NEWS to identify potentially critically ill, critically ill and terminally ill elderly patients were 6, 7 and 8, respectively. The area under the curve (AUC) for potentially critically ill, critically ill and terminally ill elderly patients was 0.907, 0.921 and 0.939, respectively. NEWS performed better in detecting patient illness severity than Modified Early Warning Score (MEWS) in AUC, sensitivity, specificity, and Youden's index, with statistically significant differences (P< 0.05). CONCLUSION: An early warning on the vital signs and consciousness of hospitalized elderly patients using NEWS can facilitate advanced detection of changes in illness severity of elderly patients by medical staff and enable timely treatment, thus significantly lowering the risks of illness deterioration.

Orally Ingested Probiotic, Prebiotic, and Synbiotic Interventions as Countermeasures for Gastrointestinal Tract Infections in Nonelderly Adults: A Systematic Review and Meta-Analysis.

Meta-analyses have not examined the prophylactic use of orally ingested probiotics, prebiotics, and synbiotics for preventing gastrointestinal tract infections (GTIs) of various etiologies in adult populations, despite evidence that these gut microbiota-targeted interventions can be effective in treating certain GTIs. This systematic review and meta-analysis aimed to estimate the effects of prophylactic use of orally ingested probiotics, prebiotics, and synbiotics on GTI incidence, duration, and severity in nonelderly, nonhospitalized adults. CENTRAL, PubMed, Scopus, and Web of Science were searched through January 2022. English-language, peer-reviewed publications of randomized, placebo-controlled studies testing an orally ingested probiotic, prebiotic, or synbiotic intervention of any dose for ≥1 wk in adults who were not hospitalized, immunosuppressed, or taking antibiotics were included. Results were analyzed using random-effects meta-analyses of intention-to-treat (ITT) and complete case (CC) cohorts. Heterogeneity was explored by subgroup meta-analysis and meta-regression. The risk of bias was assessed using the Cochrane risk-of-bias 2 tool. Seventeen publications reporting 20 studies of probiotics (n = 16), prebiotics (n = 3), and synbiotics (n = 1) were identified (n > 6994 subjects). In CC and ITT analyses, risk of experiencing ≥1 GTI was reduced with probiotics (CC analysis-risk ratio: 0.86; 95% CI: 0.73, 1.01) and prebiotics (risk ratio: 0.80; 95% CI: 0.66, 0.98). No effects on GTI duration or severity were observed. Sources of heterogeneity included the study population and number of probiotic strains administered but were often unexplained, and a high risk of bias was observed for most studies. The specific effects of individual probiotic strains and prebiotic types could not be assessed owing to a lack of confirmatory studies. Findings indicated that both orally ingested probiotics and prebiotics, relative to placebo, demonstrated modest benefit for reducing GTI risk in nonelderly adults. However, results should be interpreted cautiously owing to the low number of studies, high risk of bias, and unexplained heterogeneity that may include probiotic strain-specific or prebiotic-specific effects. This review was registered at PROSPERO as CRD42020200670.

Assessment of rotavirus and norovirus emitted from water spray park: QMRA, diseases burden and sensitivity analysis.

A quantitative model on exposure to pathogenic viruses in air of recreational area and their corresponding health effects is necessary to provide mitigation actions in content of emergency response plans (ERP). Here, the health risk associated with exposure to two pathogenic viruses of concern: Rotavirus (RoV) and Norovirus (NoV) in air of water spray park were estimated using a quantitative microbial risk assessment (QMRA) model. To this end, real-time Reverse Transcriptase polymerase chain reaction (real-time RT-PCR) was employed to measure the concentration levels of RoV and NoV over a twelve-month period. The probability of infection, illness and diseases burden of gastrointestinal illness (GI) caused by RoV and NoV for both workers and visitors were estimated using QMRA and Monto-Carlo simulation technique. The annual mean concentration for RoV and NoV in sampling air of water spray park were 20and 1754, respectively. The %95 confidence interval (CI) calculated annual DALY indicator for RoV (Workers: 2.62 × 10-4-2.62 × 10-1, Visitors: 1.50 × 10-5-2.42 × 10-1) and NoV (Workers: 5.54 × 10-3-2.53 × 10-1; Visitors: 5.18 × 10-4-2.54 × 10-1) were significantly higher the recommended values by WHO and US EPA (10-6-10-4 DALY pppy). According to sensitivity analysis, exposure dose and disease burden per case (DBPC) were found as the most influencing factors on disease burden as a consequences of exposure to RoV and NoV, respectively. The comprehensive information on DALY and QMRA can aid authorities involved in risk assessment and recreational actions to adopt proper approach and mitigation actions to minimize the health risk.

A One Health real-time surveillance system for nowcasting Campylobacter gastrointestinal illness outbreaks, Norway, week 30 2010 to week 11 2022.

BackgroundCampylobacter is a leading cause of food and waterborne illness. Monitoring and modelling Campylobacter at chicken broiler farms, combined with weather pattern surveillance, can aid nowcasting of human gastrointestinal (GI) illness outbreaks. Near real-time sharing of data and model results with health authorities can help increase potential outbreak responsiveness.AimsTo leverage data on weather and Campylobacter on broiler farms to build a risk model for possible human Campylobacter outbreaks and to communicate risk assessments with health authorities.MethodsWe developed a spatio-temporal random effects model for weekly GI illness consultations in Norwegian municipalities with Campylobacter monitoring and weather data from week 30 2010 to 11 2022 to give 1-week nowcasts of GI illness outbreaks. The approach combined a municipality random effects baseline model for seasonally-adjusted GI illness with a second model for peak deviations from that baseline. Model results are communicated to national and local stakeholders through an interactive website: Sykdomspulsen One Health.ResultsLagged temperature and precipitation covariates, as well as 2-week-lagged positive Campylobacter sampling in broilers, were associated with higher levels of GI consultations. Significant inter-municipality variability in outbreak nowcasts were observed.ConclusionsCampylobacter surveillance in broilers can be useful in GI illness outbreak nowcasting. Surveillance of Campylobacter along potential pathways from the environment to illness such as via water system monitoring may improve nowcasting. A One Health system that communicates near real-time surveillance data and nowcast changes in risk to health professionals facilitates the prevention of Campylobacter outbreaks and reduces impact on human health.

Genetic Signature and Serocompatibility Evidence for Drug Resistant Campylobacter jejuni.

Campylobacteriosis, a foodborne illness, is one of the world's leading causes of gastrointestinal illness. This study investigates the link between human campylobacteriosis and the consumption of potentially contaminated food with Campylobacter jejuni. Three hundred sixty samples were collected from humans, chicken cloaca, raw chicken meat, unpasteurized milk, and vegetables. The chickens were obtained from licensed and non-licensed slaughterhouses, and only the necks and wings were studied. Samples were enriched under microaerobic conditions then cultured on the modified charcoal cefoperazone deoxycholate agar. Bacteria was identified by staining, biochemical testing, and molecular identification by the polymerase chain reaction for the virulence genes; hipO, asp, dnaJ, cadF, cdtA, cdtB, and cdtC. The genomic homogeneity of C. jejuni between human and chicken isolates was assessed by the serological Penner test and the pulse field gel electrophoresis (PFGE). Campylobacter was not detected in the vegetables and pasteurized milk, though, only twenty isolates from chickens and clinical samples were presumed to be Campylobacter based on their morphology. The biochemical tests confirmed that five isolates were C. coli, and fifteen isolates were C. jejuni including two isolates from humans, and the remaining were from chickens. The colonization of C. jejuni in chickens was significantly lower in necks (6.66%) obtained from licensed slaughterhouses compared to those obtained from non-licensed slaughterhouses (33.3%). The antimicrobial susceptibility test showed that all identified C. jejuni isolates were resistant to antibiotics, and the majority of isolates (53.5%) showed resistance against six antibiotics, though, all isolates were resistant to ciprofloxacin, tetracycline, and aztreonam. The Penner test showed P:21 as the dominant serotype in isolates from humans, necks, and cloaca. The serohomology of C. jejuni from human isolates and chicken necks, wings, and cloaca was 71%, 36%, 78%, respectively. The PFGE analysis of the pattern for DNA fragmentation by the restriction enzyme Smal showed a complete genotypic homology of C. jejuni human isolates and chicken necks compared to partial homology with cloacal isolates. The study brings attention to the need for effective interventions to ensure best practices for safe poultry production for commercial food chain supply to limit infection with foodborne pathogens, including Campylobacter.

Cross-connections in drinking water distribution networks: Quantitative microbial risk assessment in combination with fault tree analysis and hydraulic modelling.

Deficiencies in drinking water distribution networks, such as cross-connections, may lead to contamination of the drinking water and pose a serious health risk to consumers. Cross-connections and backflows are considered among the most severe public health risks in distribution networks. The aim of this paper was to provide a framework for estimating the risk of infection from cross-connection and backflow events. Campylobacter, norovirus, and Cryptosporidium were chosen as reference pathogens for this study. The theoretical framework was constructed based on the fault tree analysis methodology. National aggregated cross-connection incident data was used to calculate the probability of a contamination event occurring in Swedish networks. Three risk cases were evaluated: endemic, elevated, and extreme. Quantitative microbial risk assessment (QMRA) was used to assess daily risk of infection for average national estimates. The framework was also evaluated using local data from the Gothenburg network. The daily risk of infection from cross-connection and backflow events in Swedish networks was generally above an acceptable target level of 10-6 for all reference pathogens and modelled cases; the exception was for the Gothenburg system where the risk was lower than 10-7. An outbreak case study was used to validate the framework results. For the outbreak case study, contaminant transport in the network was simulated using hydraulic modelling (EPANET), and risk estimates were calculated using QMRA. The outbreak simulation predicted between 97 and 148 symptomatic infections, while the epidemiological survey conducted during the outbreak reported 179 cases of illness. The fault tree analysis framework was successfully validated using an outbreak case study, though it was shown on the example of Gothenburg that local data is still needed for well-performing systems. The framework can help inform microbial risk assessments for drinking water suppliers, especially ones with limited resources and expertise in this area.

Exposure to industrial hog operations and gastrointestinal illness in North Carolina, USA.

With 9 million hogs, North Carolina (NC) is the second leading hog producer in the United States. Most hogs are housed at concentrated animal feeding operations (CAFOs), where millions of tons of hog waste can pollute air and water with fecal pathogens that can cause diarrhea, vomiting, and/or nausea (known as acute gastrointestinal illness (AGI)). We used NC's ZIP code-level emergency department (ED) data to calculate rates of AGI ED visits (2016-2019) and swine permit data to estimate hog exposure. Case exposure was estimated as the inverse distances from each hog CAFO to census block centroids, weighting with Gaussian decay and by manure amount per CAFO, then aggregated to ZIP code using population weights. We compared ZIP codes in the upper quartile of hog exposure ("high hog exposed") to those without hog exposure. Using inverse probability of treatment weighting, we created a control with similar demographics to the high hog exposed population and calculated rate ratios using quasi-Poisson models. We examined effect measure modification of rurality and race using adjusted models. In high hog exposed areas compared to areas without hog exposure, we observed a 11% increase (95% CI: 1.06, 1.17) in AGI rate and 21% increase specifically in rural areas (95% CI: 0.98, 1.43). When restricted to rural areas, we found an increased AGI rate among American Indian (RR = 4.29, 95% CI: 3.69, 4.88) and Black (RR = 1.45, 95% CI: 0.98, 1.91) residents. The association was stronger during the week after heavy rain (RR = 1.41, 95% CI: 1.19, 1.62) and in areas with both poultry and swine CAFOs (RR = 1.52, 95% CI: 1.48, 1.57). Residing near CAFOs may increase rates of AGI ED visits. Hog CAFOs are disproportionally built near rural Black and American Indian communities in NC and are associated with increased AGI most strongly in these populations.

Fecal microbiota transplant, its usefulness beyond Clostridioides difficile in gastrointestinal diseases / Trasplante de microbiota fecal, su utilidad más allá de Clostridioides difficile en enfermedades gastrointestinales

Fecal microbiota transplant (FMT) is currently recommended for recurrent Clostridioidesdifficile infection. However, it is interesting to acknowledge the potential therapeutic role in other diseases associated with dysbiosis. This review will focus on the current and potential indications of FMT in gastrointestinal diseases, evaluating the available evidence and also exposing the necessary requirements to carry it out.(AU)

El trasplante de microbiota fecal (TMF) está actualmente recomendado en la infección por Clostridioides difficile recurrente; sin embargo, es interesante conocer el potencial rol terapéutico en otras enfermedades asociadas a disbiosis. Esta revisión se enfocará en las indicaciones actuales y potenciales en enfermedades gastrointestinales de TMF, evaluando la evidencia disponible y además exponiendo los requerimientos necesarios para llevarlo a cabo.(AU)

An exploratory assessment of human and animal health concerns of smallholder farmers in rural communities of Chimborazo, Ecuador.

BACKGROUND: Livestock play important economic and cultural roles in smallholder communities of Ecuador, yet they also serve as potential sources of zoonotic infections. Understanding the animal and human health concerns of smallholder farmers is important in guiding strategies for improvement of the health and livelihoods of these resource-poor farmers. Therefore, the objectives of this study were to: (a) assess the health concerns of smallholder farmers; (b) explore animal and waste management practices; and (c) identify predictors of pediatric and livestock diarrhea on smallholder farms in Ecuador. METHODS: This is a cross-sectional survey of 58 smallholder farmers in three communities of Chimborazo province, Ecuador. Data were collected on household demographics, smallholding characteristics, type of animals owned, human-animal interactions, health concerns, and 30-day occurrence of human as well as animal diarrhea. Summary statistics were computed and logistic models used to investigate predictors of pediatric and animal diarrhea. RESULTS: All respondents reported keeping animals. Animals kept included cattle, pigs, poultry, dogs, guinea pigs, cats, sheep, horses, rabbits, donkeys, or other livestock. More than half of the respondents named diseases as their greatest personal (55.2%) or family (58.6%) health concern, while an even greater percentage (60.3%) reported physiological stress as the primary health concern for their animals. Occurrence of diarrhea in the 30 days prior to the study was reported by 12.1% of the respondents. Additionally, 15.2% and 55.2% of the households reported diarrhea among children and animals, respectively. The majority (65.5%) of the households had toilets, while the remainder had either latrines (27.6%) or no sanitation facilities (6.9%). However, only 9.1% of the smallholdings had either a toilet (3.6%) or a latrine (5.5%) onsite and yet the farmers tended to spend most of the day at the smallholdings. Potential exposures to gastrointestinal pathogens included food- or water-borne sources (93.5% of children; 91.4% of adults) and blood-borne or fecal sources (80.4% of children; 100% of adults). Although 98.3% of the respondents kept cattle, only 27.6% had animal enclosures and even fewer (15.5%) had animal waste management plans. The odds of animal diarrhea were significantly higher (Odds Ratio [OR] = 8.7; 95% Confidence Interval [1.0-75.0]; p = .049) among households that had animal waste management plans compared to those that did not. None of the variables investigated were significant predictors of pediatric diarrhea. CONCLUSIONS: Ongoing surveillance is needed to develop estimates of diarrhea incidence among smallholder families and their livestock. The impact of different animal management strategies on the potential pathogen exposure of smallholders warrants further investigations. Improving sanitation infrastructure and animal waste management strategies is recommended.

'We don't use the same ways to treat the illness:' A qualitative study of heterogeneity in health-seeking behaviour for acute gastrointestinal illness among the Ugandan Batwa.

The Batwa (Twa), an Indigenous People of southwest Uganda, were evicted from their ancestral forest lands in 1991 due to establishment of the Bwindi Impenetrable Forest. This land dispossession forced Batwa to transition from a semi-nomadic, hunting-gathering livelihood to an agricultural livelihood; eliminated access to Indigenous food, medicines, and shelter; and shifted their healthcare options. Therefore, this exploratory study investigated why Batwa choose Indigenous or biomedical treatment, or no treatment, when experiencing acute gastrointestinal illness. Ten gender-stratified focus groups were conducted in five Batwa settlements in Kanungu District, Uganda (n = 63 participants), alongside eleven semi-structured interviews (2014). Qualitative data were analysed thematically, using a constant comparative method. Batwa emphasised that health-seeking behaviour for acute gastrointestinal illness was diverse: some Batwa used only Indigenous or biomedical healthcare, while others preferred a combination, or no healthcare. Physical and economic access to care, and also perceived efficacy and quality of care, influenced their healthcare decisions. This study provides insight into the Kanungu District Batwa's perceptions of biomedical and Indigenous healthcare, and barriers they experience to accessing either. This study is intended to inform public health interventions to reduce their burden of acute gastrointestinal illness and ensure adequate healthcare, biomedical or Indigenous, for Batwa.

Hurricane flooding and acute gastrointestinal illness in North Carolina.

Hurricanes often flood homes and industries, spreading pathogens. Contact with pathogen-contaminated water can result in diarrhea, vomiting, and/or nausea, known collectively as acute gastrointestinal illness (AGI). Hurricanes Matthew and Florence caused record-breaking flooding in North Carolina (NC) in October 2016 and September 2018, respectively. To examine the relationship between hurricane flooding and AGI in NC, we first calculated the percent of each ZIP code flooded after Hurricanes Matthew and Florence. Rates of all-cause AGI emergency department (ED) visits were calculated from NC's ED surveillance system data. Using controlled interrupted time series, we compared AGI ED visit rates during the three weeks after each hurricane in ZIP codes with a third or more of their area flooded to the predicted rates had these hurricanes not occurred, based on AGI 2016-2019 ED trends, and controlling for AGI ED visit rates in unflooded areas. We examined alternative case definitions (bacterial AGI) and effect measure modification by race and age. We observed an 11% increase (rate ratio (RR): 1.11, 95% CI: 1.00, 1.23) in AGI ED visit rates after Hurricanes Matthew and Florence. This effect was particularly strong among American Indian patients and patients aged 65 years and older after Florence and elevated among Black patients for both hurricanes. Florence's effect was more consistent than Matthew's effect, possibly because little rain preceded Florence and heavy rain preceded Matthew. When restricted to bacterial AGI, we found an 85% (RR: 1.85, 95% CI: 1.37, 2.34) increase in AGI ED visit rate after Florence, but no increase after Matthew. Hurricane flooding is associated with an increase in AGI ED visit rate, although the strength of effect may depend on total storm rainfall or antecedent rainfall. American Indians and Black people-historically pushed to less desirable, flood-prone land-may be at higher risk for AGI after storms.

Fecal microbiota transplant, its usefulness beyond Clostridioides difficile in gastrointestinal diseases.

Fecal microbiota transplant (FMT) is currently recommended for recurrent Clostridioidesdifficile infection. However, it is interesting to acknowledge the potential therapeutic role in other diseases associated with dysbiosis. This review will focus on the current and potential indications of FMT in gastrointestinal diseases, evaluating the available evidence and also exposing the necessary requirements to carry it out.

Childhood parasitic infections and gastrointestinal illness in indigenous communities at Lake Atitlán, Guatemala.

Lake Atitlán has experienced a decline in water quality resulting from cultural eutrophication. Indigenous Mayans who already face disproportionate health challenges rely directly on the lake water. Our objectives were to: (1) estimate prevalence of shedding of water-borne fecal parasites among children 5 years of age and younger, (2) assess household-reported incidence of gastrointestinal illness in children, and (3) characterize water sources, treatment, and sanitation conditions in households. We hypothesized that household use of untreated lake water results in increased risk of shedding of parasites and gastrointestinal symptoms. A cross-sectional fecal sampling and physical exam of 401 children were conducted along with WASH surveys in partnership with healthcare providers in seven communities. Fecal samples were screened for Giardia lamblia and Cryptosporidium parvum, using a rapid ELISA, with a portion examined by microscope. The prevalence of parasite shedding was 12.2% (9.7% for Giardia; 2.5% for Cryptosporidium). Risk factors for Giardia shedding included age 3 years or older (3.4 odds ratio, z-stat = 2.781 p = 0.0054), low height-for-age z-score (2.3 odds ratio, z-stat = 2.225, p = 0.0216), lack of any household water treatment (2.5 odds ratio, z-stat = 2.492, p < 0.0012), and open access to household latrine (2.04 odds ratio, z-stat = 1.992, p = 0.0464). The majority (77.3%) of households reported water treatment, boiling and gravity fed filters as the most widespread practices. The vast majority of households (92%) reported usage of a latrine, while 40% reported open and shared access beyond their household. An overwhelming majority of households reported diarrhea and fever several times per year or greater, with approximately half reporting vomiting at that frequency. Lake water use was identified as a risk factor for households reporting frequent gastrointestinal symptoms (odds ratio of 2.5, 4.4, and 2.6; z-stat of 3.10, 3.65, and 3.0; p-values of 0.0021, 0.0003, and 0.0028, for diarrhea, vomiting, and fever, respectively) in children 5 years of age and younger. The frequency of gastrointestinal illness with a strong link to lake drinking water cannot be explained by the prevalence of protozoa, and risk from other enteropathogens must be explored. Improving access to water treatment and sanitation practices could substantially reduce the parasite burden faced by developing children in the region.

The effectiveness of syndromic surveillance for the early detection of waterborne outbreaks: a systematic review.

BACKGROUND: Waterborne outbreaks are still a risk in high-income countries, and their early detection is crucial to limit their societal consequences. Although syndromic surveillance is widely used for the purpose of detecting outbreaks days earlier than traditional surveillance systems, evidence of the effectiveness of such systems is lacking. Thus, our objective was to conduct a systematic review of the effectiveness of syndromic surveillance to detect waterborne outbreaks. METHOD: We searched the Cochrane Library, Medline/PubMed, EMBASE, Scopus, and Web of Science for relevant published articles using a combination of the keywords 'drinking water', 'surveillance', and 'waterborne disease' for the period of 1990 to 2018. The references lists of the identified articles for full-text record assessment were screened, and searches in Google Scholar using the same key words were conducted. We assessed the risk of bias in the included articles using the ROBINS-I tool and PRECEPT for the cumulative body of evidence. RESULTS: From the 1959 articles identified, we reviewed 52 articles, of which 18 met the eligibility criteria. Twelve were descriptive/analytical studies, whereas six were simulation studies. There is no clear evidence for syndromic surveillance in terms of the ability to detect waterborne outbreaks (low sensitivity and high specificity). However, one simulation study implied that multiple sources of signals combined with spatial information may increase the timeliness in detecting a waterborne outbreak and reduce false alarms. CONCLUSION: This review demonstrates that there is no conclusive evidence on the effectiveness of syndromic surveillance for the detection of waterborne outbreaks, thus suggesting the need to focus on primary prevention measures to reduce the risk of waterborne outbreaks. Future studies should investigate methods for combining health and environmental data with an assessment of needed financial and human resources for implementing such surveillance systems. In addition, a more critical thematic narrative synthesis on the most promising sources of data, and an assessment of the basis for arguments that joint analysis of different data or dimensions of data (e.g. spatial and temporal) might perform better, should be carried out. TRIAL REGISTRATION: PROSPERO: International prospective register of systematic reviews. 2019. CRD42019122332 .

Evidence of False Positivity for Vibrio Species Tested by Gastrointestinal Multiplex PCR Panels, Minnesota, 2016-2018.

BACKGROUND: Syndromic gastrointestinal multiplex polymerase chain reaction (PCR) panels (GMPPs) are used by an increasing number of clinical laboratories to identify enteric pathogens. Vibrio species are included on GMPPs, but because of the low prevalence of vibriosis, performance characteristics for these panels have been difficult to measure. METHODS: All Vibrio spp. cases identified by GMPPs in Minnesota during 2016-2018 (n = 100) were assessed to identify differences between culture-confirmed cases and those that were PCR-positive only. RESULTS: Overall, 47% of cases had Vibrio species recovered by culture. Two GMPPs were used in Minnesota, Verigene EPT and FilmArray GIP, and the recovery rate of Vibrio spp. was significantly different between these platforms (Verigene EPT 63%, compared with FilmArray GIP 28%). No distinct seasonality was identified among GMPP-positive, culture-negative cases, whereas culture-confirmed case incidence peaked during July and August. Among cases with no other pathogen detected by the GMPP, confirmed cases reported a lower rate of bloody diarrhea (odds ratio [OR], 0.7; P = .004) and were less likely to have a symptom duration >14 days (OR, 0.3; P = .04). Confirmed cases were also more likely to include reports of consuming food items typically associated with Vibrio spp. infection or to have another likely source of infection (eg, international travel or contact with an untreated body of fresh or salt water or marine life; OR, 9.6; P = .001). CONCLUSIONS: The combined findings indicate that cases identified by GMPP that did not have culture confirmation were less likely to include symptoms or exposures consistent with vibriosis. These findings emphasize the need for improvements to testing platform specificity and the importance of combining clinical and exposure information when diagnosing an infection. This study underscores the importance of maintaining the ability to culture Vibrio species to aid in accurate diagnoses.

Health-related quality of life in youth with abdominal pain: An examination of optimism and pain self-efficacy.

OBJECTIVES: Abdominal pain adversely impacts children with functional gastrointestinal disorders (FGIDs) or organic gastrointestinal disorders (OGIDs); findings are inconsistent regarding diagnosis and health-related quality of life (HRQoL). This study utilizes a positive psychology framework to understand the experience of youth with abdominal pain (i.e., do positive psychological factors, such as optimism and pain self-efficacy, relate to higher HRQoL?). Consistent with a protective factor model of resilience, in which personal assets may serve as buffers between risk factors and negative outcomes, optimism and pain self-efficacy were examined as they relate to HRQoL in youth with abdominal pain. Specifically, exploratory moderational analyses examined a) if optimism and pain self-efficacy moderate the relation between pain and HRQoL, and b) whether diagnostic status moderated the relation between optimism/pain self-efficacy and HRQoL. METHODS: In a cross-sectional, observational study, youth (n = 98; Mage = 13, SD = 3) experiencing abdominal pain related to FGIDs or OGIDs and one of their parents participated. Measures included pain intensity, optimism, pain self-efficacy, and HRQoL. Analyses controlled for diagnosis, age, and gender. RESULTS: Higher pain and age related to lower HRQoL. Higher levels of optimism and pain self-efficacy associated with HRQoL beyond demographics. Optimism and pain self-efficacy did not moderate the relation between pain and HRQoL. Diagnostic status did not moderate the relation between optimism or pain self-efficacy and HRQoL. DISCUSSION: Our results suggest positive relations between positive psychological factors (optimism, pain self-efficacy) and HRQoL in youth with abdominal pain. Such factors could be further examined in intervention studies.