Day care center attendance and diarrheal morbidity in Colombia.

This study was designed to determine whether day care center attendance was associated with increased risk of diarrheal disease among poor children in an urban, developing country setting. From July 17 to December 18, 1988, mothers of 493 Colombian children less than 5 years old (241 attendees and 252 nonattendees) were interviewed weekly about diarrheal events during the previous week. The incidence of diarrhea was greater for day care center attendees than for nonattendees (3.2 vs 2.0 episodes per child-year, P < .0005). For children less than 2 years of age, attendees experienced 7.2 episodes/child-year vs 3.5 episodes per child-year for nonattendees (P < .0005). Analyses controlling for water source and availability, excreta disposal, socioeconomic status, and duration of follow-up showed that the increased diarrheal risk was limited to children younger than 3 years of age spending more than 30 hours per week in the centers. In addition, although the risk among attendees of suffering diarrheal episodes of longer duration was fairly constant across levels of socioeconomic status, this risk was inversely proportional to socioeconomic status for nonattendees. In summary, the increase in risk of diarrhea among young, full-time day care attendees was modest, yet important, because diarrhea continues to be a major cause of morbidity and mortality in Colombian children.     

Epidemiology of persistent diarrhea and etiologic agents in Mirzapur, Bangladesh

To determine the epidemiology and etiologic agents of persistent diarrhea we carried out an intensive diarrhea surveillance on children less than six years old in rural Bangladesh. From March 1987 to February 1989 we examined 363 children through diarrhea recall interviews and analyzed stool samples of all diarrhea cases for potential pathogens. Results showed that children had an average of two episodes per year and the incidence rate of diarrheal episodes denned as acute (<14 d) and persistent (14 d) varied similarly with age. The peak incidence (episodes/child/year) of acute diarrhea (2.8) and persistent diarrhea (0.8) occurred in the 6-11 months age group. The data showed that an episode tended to be prolonged if the stool was loose/mucoid or bloody at onset. Aggregative adherent Escherichia coli was found significantly more often at onset in persistent than in acute episodes, whereas Shigella, Aeromonas, Giardia and toxigenic E. coli were isolated with less frequency in persistent than acute episodes. This suggests that other factors might be more important in the development of persistent diarrhea than specific pathogens.     

Enteric adenovirus infection and childhood diarrhea: an epidemiologic study in three clinical settings

During a 2-year prospective study of gastroenteritis in children less than 2 years of age, the role of enteric adenovirus as a cause of infantile diarrhea was examined in three clinical settings in a case-control fashion. Using a monoclonal antibody-based enzyme-linked immunosorbent assay with specificity for adenovirus serotypes 40 and 41, enteric adenovirus was identified in 10 of 246 episodes of diarrhea in outpatients (4.1%), 13 of 211 children admitted to the hospital with diarrhea (6.2%), and 5 of 81 children in whom nosocomial diarrhea developed (6.2%), making this agent the third most commonly identified etiologic agent of diarrheal disease. Asymptomatic infections were uncommon (5 of 372 control subjects, or 1.3%) and were seen most frequently in the nosocomial setting. Cases occurred in every calendar month except March and April of each year. A syndrome of watery diarrhea of longer duration compared with other patients with diarrhea (mean 5.4 vs 3.8 days, P = .01), associated with vomiting and dehydration, was present in most cases. Compared with patients with rotavirus, patients were as likely to experience fever and dehydration and more likely to vomit. Household contact with gastroenteritis, often with a child 2 to 5 years of age, was a predisposing factor. It was concluded that enteric adenovirus is an important cause of infantile diarrhea in Baltimore children. Although far less common than rotavirus, this agent was associated with diarrheal illnesses that were at least as severe as those seen with rotavirus.     

Persistent diarrhea in Northeast Brazil: etiologies and interactions with malnutrition

With the improved control of acute diarrheal illness mortality with oral rehydration therapy, persistent diarrhea is now emerging as a major cause of childhood mortality in tropical developing areas like the impoverished populations in Brazil's Northeast. "Graveyard surveillance" in the rural community of Guaiuba in northeastern Brazil revealed fully half of the 70% diarrhea mortality was due to persistent diarrheal illnesses. Furthermore, 11% of 14 or more diarrheal illnesses per child per year in an urban slum in Fortaleza persisted beyond 14 days, a definition that clearly identified the high risk children for heavy diarrhea burdens. Not only did heavy diarrhea burdens ablate the key "catch-up" growth seen in severely malnourished children and in children following previous diarrheal illnesses, but malnutrition significantly predisposed children to a greater incidence and duration of diarrhea as well as a greater incidence of persistent diarrhea. Etiologic studies of 37 children presenting with persistent diarrhea to Hospital das Clinicas in Fortaleza revealed that Cryptosporidium (in 13%) and enteroadherent E. coli (36% with aggregative, 29% with diffuse and 13% with localized adherence to HEp-2 cells) were the predominant potential pathogens found in the stool or upper small bowel. These findings suggest that persistent diarrhea is emerging as an important health problem in Brazil's Northeast, that it identifies a high risk child for heavy diarrhea burdens, that important interactions occur with malnutrition and that Cryptosporidium and enteroadherent E. coli warrant further study as potential etiologies of this major cause of morbidity and mortality.     

Diarrheal illness among infants and toddlers in day care centers. I. Epidemiology and pathogens

We conducted a 2-year prospective study of diarrheal illness in children ages 0 to 36 months in 22 day care centers in Maricopa County, Arizona. In 7464 child-months of observation, 465 sporadic cases and 170 outbreak-associated cases of diarrhea were identified. Enteric pathogens were identified in 20% of diarrhea episodes. Giardia lamblia, rotavirus, and Campylobacter jejuni were the most common pathogens. Giardia was significantly more common in toddlers than in infants and was found in 19% of asymptomatic child contacts of symptomatic infected children. Rotavirus was significantly more common in infants than in toddlers. In outbreaks, shorter duration of child enrollment was associated with illness. Comparison of day care center characteristics revealed that only a lower score in standardized observations of hygiene and child-handling practices was associated with greater risk of diarrhea. Infectious diarrhea appears to be common in diaper-age children in day care centers, but the patterns of disease differ for different pathogens and for the infant and toddler age groups.     

Hemolytic uremic syndrome and diarrhea associated with Escherichia coli O157:H7 in a day care center

Three cases of hemolytic uremic syndrome with bloody diarrhea occurred during an outbreak of diarrheal illness in children aged 4 months to 9 years who attended a day care center. Thirty-six (34%) of 107 had diarrhea (three or more loose or watery stools in 24 hours) lasting greater than or equal to 3 days. Thirty-one (48%) of 64 children younger than 4 years of age but only (12%) of 43 in the older classes became ill (relative risk 4.0, P less than 0.001). Eleven (31%) of the 36 children with diarrhea had blood in their stools. Sequential movement of illness from class to class was consistent with person-to-person spread. Ten (18%) of 56 family members of ill children but only one of 45 family members of well children younger than 4 years of age developed a diarrheal illness (P less than 0.05). Escherichia coli O157:H7 was detected in two of eight stool specimens from children who had bloody diarrhea (one with hemolytic uremic syndrome), two of seven with nonbloody diarrhea, and none of nine who remained well. All three stool specimens obtained at less than or equal to 6 days compared with one of nine obtained at greater than 6 days after onset yielded this organism (P less than 0.02). E. coli O157:H7 can cause hemolytic uremic syndrome and both nonbloody and bloody diarrhea, and can spread within families and through modes other than foodborne transmission.     

Rotavirus disease in young children from Hanoi, Vietnam

BACKGROUND: Pathogen prevalences and antimicrobial susceptibilities are essential for the rational development of preventive strategies for diarrheal diseases, but little recent information from Vietnam is available. We prospectively studied the prevalence of enteric pathogens in children less than 5 years of age with acute diarrhea and in nondiarrhea controls in a city hospital in Hanoi, Vietnam for 1 year. METHODS: Enteric bacteria and viruses were detected by standard culture methods, and enzyme immunoassay in 291 cases and 291 controls. RESULTS: Detection rates of viral pathogens among cases and controls were 31% and 3% for rotavirus, 12% and 1% for astrovirus and 4% and 1% for adenovirus. For bacterial pathogens, Aeromonas, Shigella, Salmonella, Campylobacter and enterotoxigenic E. coli were isolated from cases and controls in 15% and 8%, 9% and 1%, 7% and 1%, 4% and 0%, and 3% and 0%, respectively. The isolation of bacterial and viral pathogens except for adenovirus was significantly lower in controls than cases. Fluoroquinolones were effective against most bacterial enteropathogens, but resistance was observed in 27% of Campylobacter isolates. CONCLUSIONS: Viral etiologic agents especially rotavirus were the most important cause of acute diarrhea in children less than 5 years of age in Hanoi. The burden of rotavirus in young children in Hanoi warrants consideration of using the recently released rotavirus vaccine.     

Community-based evaluation of the effect of breast-feeding on the risk of microbiologically confirmed or clinically presumptive shigellosis in Bangladeshi children.

To assess the association between breast-feeding and the risk of microbiologically confirmed or clinically presumptive shigellosis, the authors performed a case-control analysis of Bangladeshi children younger than 3 years of age who were followed up for 1 month after exposure to Shigella in their residential neighborhoods. Two hundred sixty-nine cases with culture-confirmed shigellosis (n = 119) or clinically presumptive shigellosis (culture-negative dysentery, n = 150) were compared with 819 controls without Shigella diarrhea or other invasive diarrheal illnesses. The odds ratio relating breast-feeding to confirmed or presumptive shigellosis, adjusted for potentially confounding variables, was 0.48 (95% confidence interval = 0.32 to 0.72; P less than .001), suggesting a substantial protective effect. The protective association decreased with age but was still significant during the third year of life; appeared to be directly related to the degree of stunting; and was equivalent for confirmed and presumptive shigellosis. Notably, the protective association remained substantial against episodes due to Shigella which were resistant to at least one of the antibiotics customarily used for treatment of Shigella diarrhea (age-adjusted odds ratio = 0.40; 95% confidence interval = 0.22 to 0.74; P less than .01). These data suggest that breast-feeding confers a high level of protection against shigellosis throughout the first 3 years of life, especially among nutritionally compromised children, and thereby underscore the importance of promotion of breast-feeding as a central component of Shigella control programs in less developed settings.     

Potential role of adherence traits of Escherichia coli in persistent diarrhea in an urban Brazilian slum.

We examined stools from 40 children with persistent diarrhea (duration, 14 days or more), from 50 children with acute diarrhea and from 38 control children to determine infectious etiologies for persistent diarrhea in Goncalves Dias, an urban favela (slum) in Fortaleza, Ceara, Brazil. Children with persistent diarrhea and children with acute diarrhea had similar rates of isolation of routine viral, bacterial and parasitic enteric pathogens. Routine pathogens were identified in at least 20% of cultures done more than 14 days into the diarrheal illness. We examined Escherichia coli isolated from these stools for adherence potential. Enteroaggregative E. coli were isolated significantly more often from children with persistent diarrhea than from control children or children with acute diarrhea (P less than 0.05). E. coli with hemagglutination patterns suggestive of adherence pili were also isolated more often from children with persistent diarrhea than from children with acute diarrhea (38% vs. 18%; P less than 0.05). Enterotoxigenic E. coli were isolated in combination with rotavirus more often from children with persistent diarrhea than from children with acute diarrhea. E. coli which were hydrophobic or exhibited hemagglutination were also seen more often in association with Giardia in children with persistent diarrhea. These findings suggest that the etiology of persistent diarrhea in children is complex and that the aggregative E. coli are associated with prolonged diarrheal illness. Although routine diarrheal pathogens may be present for more than 14 days, combinations of pathogens, including E. coli with adherence potential, may also contribute to prolonged diarrheal disease.     

Diarrhea in children newly enrolled in day-care centers in Houston

Diarrhea is a common illness among children in day-care centers (DCC). We hypothesized that the incidence of diarrhea was greater among children in their first 1 or 2 months after enrollment in a DCC than in any subsequent period in day care. We followed 442 children younger than 2 years of age enrolled in 13 randomly selected DCCs for the occurrence of diarrhea during a 14 1/2-month period. Parents completed standardized baseline questionnaires and research nurses visited the DCC twice weekly to record the occurrence of diarrhea and to collect stool specimens. Incidence rates, rate ratios, chi square statistics and 95% confidence intervals were calculated for crude and stratified analyses. The diarrheal incidence rate of 4.4 cases/child-year in the first 4 weeks in the centers was significantly (rate ratio, 1.6; confidence interval, 1.3 to 2.1; P less than 0.01) higher than the 2.7 cases/child-year incidence rate of diarrhea in subsequent weeks. The effects of gender, ethnicity, age, DCC size, previous DCC attendance and season were examined and did not account for the association observed between recent enrollement and risk of diarrheal illness. Rotavirus was identified in 18% of cases of diarrhea, but no association was seen with recent enrollment in DCC. A significantly higher incidence of diarrhea occurred in males compared with females (P less than 0.002) and in younger children (P less than 0.001) compared with older children. Diarrhea is common in children in DCCs and occurs significantly more frequently in children during their first 4 weeks in a DCC.     

Effects of nutritional status on diarrhea in Peruvian children

OBJECTIVES: We conducted a 4-year (1995-1998) field study in a Peruvian peri-urban community (pueblo joven) to examine the relation between diarrhea and nutritional status in 230 children <3 years of age. METHODS: We followed the birth cohort daily for diarrhea and monthly for anthropometry. We modeled diarrheal incidence with a multivariate time-to-event regression model to account for multiple episodes per child and irregular follow-up periods and diarrheal duration with a mixed-effects gamma regression model to account for disease heterogeneity across children. RESULTS: During 159,551 child-days of follow-up, we identified 1387 diarrheal episodes, which yielded an average incidence of 3.2 episodes per child-year. Diarrhea was seasonal, for example, infants had up to 8 diarrheal episodes during the summer; however, these variations decreased noticeably with age. Nutritional status was significantly associated with diarrheal incidence. The frequency of diarrhea increased by 15% per standard deviation decrease in height-for-age z score. Diarrheal episodes in children <6 months of age lasted significantly longer than episodes among older children. CONCLUSIONS: These results identify infants and children of poor nutritional status as priority risk groups for prevention efforts aimed at reducing the burden of acute childhood diarrhea.     

Prolonged and recurring diarrhea in the northeast of Brazil: examination of cases from a community-based study

From prospective daily surveillance of diarrhea in a poor rural area of northeastern Brazil, this study of prolonged diarrheal episodes identified the 3% of diarrheal episodes that lasted 15 days or longer. These episodes also defined a subpopulation of children who spent over 16% of their days with diarrhea. Such children warrant further attention in an attempt to define potentially treatable causes as well as to assure appropriate nutritional support. There was no single season for these prolonged illnesses, but they appeared to involve both the wet, slightly warmer season of peak enterotoxigenic Escherichia coli diarrhea as well as the dry, slightly cooler season of peak rotaviral infections. Limited etiologic data support this idea that multiple pathogens are found, often in combination with each other, that may work together to contribute to the important problem of chronic diarrhea. Future studies should focus attention on further defining risk factors, mechanisms, and appropriate therapy for the subset of children who experience prolonged diarrhea in this type of setting.     

Epidemiology of postshigellosis persistent diarrhea in young children

BACKGROUND: Dysentery accounts for 20% of the 4.6 million diarrhea-associated deaths among children in developing countries, with the risk from death in dysenteric persistent diarrhea 10-fold higher than that in acute dysentery. Although Shigella accounts for the majority of dysenteric episodes, very little is known about the epidemiology of postshigellosis persistent diarrhea. METHODS: Rural Bangladeshi children younger than 5 years of age (n = 1,756) were followed for 1 month after exposure to sentinel cases of Shigella dysentery. The likelihood of an acute diarrheal episode becoming persistent was assessed. RESULTS: Diarrhea caused by Shigella was significantly associated with an increased risk of persistent diarrhea (age-adjusted relative risk, 1.83; 95% confidence interval, 1.19 to 2.81). Despite the use of nalidixic acid in dysenteric episodes, persistent diarrhea occurred in 23% of children with shigellosis. Infection by multiply antibiotic-resistant Shigella isolates (age-adjusted relative risk, 3.76; 95% confidence interval, 1.51 to 9.36) and occurrence of shigellosis during infancy were observed to be risk factors for initiation of Shigella diarrhea persistence. However, 88% of the persistent shigellosis episodes occurred in older children, 50% were associated with nondysenteric shigellosis and 79% were caused by Shigella species other than Shigella dysenteriae 1. CONCLUSIONS: These data demonstrate the importance of Shigella as a cause of persistent diarrhea and indicate that strategies to prevent postshigellosis persistent diarrhea must be broad-based, with a focus on older children as well as infants, management of nondysenteric as well as dysenteric disease and prevention of diarrhea caused by multiple Shigella species.     

Recommendations for the use of rotavirus vaccines in infants

Rotavirus infection occurs in the majority of healthy children before five years of age, and is the most common diarrheal illness associated with hospitalization. The majority of children present with symptoms of vomiting, diarrhea and fever. As a result, rotavirus gastroenteritis is responsible for greater morbidity than other common childhood diarrheal illnesses. The highest risk of severe disease is in children younger than two years of age. It is estimated that one in 20 children will require an emergency department visit. In addition to community-acquired infections, hospital-acquired infections are also significant. There are currently two licensed rotavirus vaccines in Canada. Both vaccines are administered orally and are highly effective against severe disease and hospitalization. Large pre- and postmarketing studies have shown no increased risk of intussusception with the current rotavirus vaccines. The present statement provides information concerning the clinical disease and rotavirus vaccines in Canada.     

Morbidity and mortality in diarrhea in rural Haryana

Five thousand children under 6 years of age from 69 villages in Haryana were followed up for 2 years to assess the extent and severity of acute diarrheal disease. Almost 70–75 per cent of children suffered from diarrhea every year. The annual attack rate was 1·92/child during the first year and 2·16/child in the second year. Thirty four per cent suffered from 3 or more episodes. Maximum attack rate of 2·69/child/year was seen in children 1–2 years of age. No severe dehydration was seen and one or more signs of dehydration were reported in 3013 (12·2%) cases. Diarrhea accounted for 23·1 per cent (27) of total deaths (117) during the study period. The case fatality rate in 7424 episodes of diarrhea was 3·63/1000 episodes. The findings of this prospective study have operational and logistic implications in national diarrheal disease control programme and may strengthen the monitoring of the desease.     

Morbidity and mortality in diarrhea in rural Haryana

Five thousand children under 6 years of age from 69 villages in Haryana were followed up for 2 years to assess the extent and severity of acute diarrheal disease. Almost 70–75 per cent of children suffered from diarrhea every year. The annual attack rate was 1·92/child during the first year and 2·16/child in the second year. Thirty four per cent suffered from 3 or more episodes. Maximum attack rate of 2·69/child/year was seen in children 1–2 years of age. No severe dehydration was seen and one or more signs of dehydration were reported in 3013 (12·2%) cases. Diarrhea accounted for 23·1 per cent (27) of total deaths (117) during the study period. The case fatality rate in 7424 episodes of diarrhea was 3·63/1000 episodes. The findings of this prospective study have operational and logistic implications in national diarrheal disease control programme and may strengthen the monitoring of the desease.     

The parental appraisal of the morbidity of diarrhea in infants and toddlers (PAMODI) survey

This study analyzed parental perception of the impact of diarrhea on quality of life of their children. A standardized questionnaire was completed by 2023 parents in Germany with children with diarrhea who were younger than 2 years old. Parents stated the most worrying aspects of diarrhea. A health score was measured using a visual analogue scale (0 = worst health, 100 = best health). Clinical symptoms were quoted by 72% of parents as one of the most worrying dimensions, with duration/frequency of diarrhea and weight loss perceived most meaningful. Next were behavioral/physical symptoms (51%), with an inflamed bottom for mild disease and pain for severe cases being most meaningful. Parental concern is characterized by sympathy and anxiety for the child. The health score for the diarrheal episode was 54.6 for mild and 33.9 for severe cases. Parents perceive a high disease burden of diarrhea and clinically less meaningful aspects play a significant role.     

Persistent diarrhea in Vietnamese children: a preliminary report

The clinical and laboratory features of persistent diarrhea were investigated in 83 children under three years of age who were treated in the Gastroenterology Division of the Institute for the Protection of Children's Health, Hanoi from August 1988 to August 1989. The number of cases of diarrhea was highest in the children aged 4-5 months. The mean age of the children studied was 6.6 ± 3.4 months. The ratio of males to females was 2.6 and mean age of first episode of diarrhea was 4.3 ± 3.4 months; persistent diarrhea was more common in children under six months of age than in older children. Persistent diarrhea occurred in the first diarrheal episode in 66.5% of cases. Recent nonenteric infections were found in 30% of the study group. Of the 83 children studied, 36% had stool specimens positive for enteric pathogens; 24% had enterotoxigenic Escherichia coli isolated, 8% had enteropathogenic E. coli , 5% rotavirus, 6% Candida , and 4% Giardia lamblia. The duration of diarrhea was longer in children who received antibiotics than in those who did not ( p <0.01).     

Diarrhea in American infants and young children in the community setting: incidence, clinical presentation and microbiology

OBJECTIVE: The characteristics and microbiology of the full spectrum of pediatric diarrhea occurring in the U.S. community setting are not well-understood. METHODS: Six-month prospective cohort study of 604 healthy 6- to 36-month-old children recruited by the Slone Center Office-based Research Network. RESULTS: The incidence of parent-defined diarrhea was 2.2 episodes per person-year. The median duration of diarrhea was 2 days with a median of 6 stools per episode. Outpatient visits and hospitalization were prompted by 9.7 and 0.3% of episodes, respectively. The most common microorganisms identified in healthy baseline stools were atypical enteropathogenic Escherichia coli (12.2%), enteroaggregative Escherichia coli (3.7%), Clostridium difficile (3.5%) and Clostridium perfringens (2.9%), and each of these was no more common in diarrhea stools. In contrast, all of the viruses analyzed were more prevalent in diarrhea specimens than in baseline specimens: enteric adenovirus (5.7% diarrhea versus 1.4% baseline), rotavirus (5.2% versus 1.4%), astrovirus (3.5% versus 1.4%), Sapporo-like virus (3.0% versus 0.8%) and norovirus (1.9% versus 0.8%). A likely pathogen was detected in 20.6% of diarrhea specimens. Vomiting and > or =16 stools in an episode were predictive of isolating a pathogen from the stool, each with a relative risk of approximately 2. CONCLUSIONS: Healthy young children in this study experienced more than 2 cases of diarrhea per person-year, but most were brief and do not require medical attention. Although most diarrhea-associated pathogens were viruses, no likely pathogen was found in almost 80% of cases; possible etiologies for these cases include currently unknown gastrointestinal infections, nongastrointestinal illnesses and dietary/environmental factors.