Impact of type A influenza on children: a retrospective study.

Excess morbidity was studied during influenza A epidemics (1968-69, 1972-73) among children in a large prepaid group practice program. Excess rates of hospitalization for influenza-related conditions, primarily pneumonia and bronchitis, ranged from 5 per 10,000 (95 per cent confidence limits (CL): 1 to 9) for non-high-risk children to 29 per 10,000 (95 per cent CL: 5 to 53) for children with high-risk conditions. The relative increases in hospitalization rates were greatest for 5-14 year old boys: 278 per cent and 104 per cent increases for high-risk and non-high-risk boys, respectively. The absolute increase was greatest for 0-4 year olds. The excess rate of ambulatory medical care contacts, 2.6 per 100 (95 per cent CL: -1.6 to 6.8 per 100) was not statistically significant. Excess hospitalization rates among 0-14 year olds during epidemics were three to five times larger than those for persons between 15 and 64 years of age but only one-fifth the rate of persons over age 65.     

Haemolytic-uraemic syndrome in Western Australia, 1980 to 1994

Abstract: A retrospective, population-based study of patients hospitalised with the haemolytic-uraemic syndrome in Western Australia from 1980 to 1994 was undertaken to describe the epidemiology of the disease in this state. We identified 41 patients. Episodes were commonest in children under five years of age (63.4 per cent) and were more frequent in females (58.5 per cent) than in males; only one Aboriginal patient was detected. More than 90 per cent of episodes had a gastrointestinal prodrome lasting from one to 22 days; in 47.6 per cent of these episodes patients had bloody diarrhoea. The average hospital stay was 26 days, and 63.4 per cent of patients required dialysis (mean 10 days). More than 20 per cent of patients developed chronic renal failure, 9.7 per cent died, two patients developed hypertension and one child became epileptic; three of the 10 patients over 16 years of age (30 per cent) died. The haemolytic-uraemic syndrome is potentially fatal, affects mostly young children, and is usually preceded by a gastrointestinal illness. Episodes can occur in common-source outbreaks but, with the exceptions of related cases in families, that appears not to have been so in Western Australia since 1980. There is a need for increased awareness of the haemolytic-uraemic syndrome to enhance prospects for earlier detection and better clinical outcomes. Improved public health surveillance is also needed to reduce the risks of the syndrome in the community.     

Persistent diarrhoea in a rural area of Bangladesh: a community-based longitudinal study

As part of a health impact evaluation of a water supply and sanitation project in a rural area of Bangladesh, diarrhoeal morbidity was recorded in children 0-4 years of age using weekly recall in household interviews, during the period March 1984 to December 1987. During the baseline year, 1984, the incidence rate of all diarrhoea episodes (3.8 episodes per child per year), and those defined as persistent, duration greater than 14 days (0.6 episodes per child per year), showed a similar age distribution, peaking in the 12-23 month age group. Sixteen per cent of all episodes were classified as persistent, and this proportion was greatest in the 0-5 month age group (25%). Children suffering at least one episode of persistent diarrhoea in 1984 also experienced a higher incidence of acute diarrhoea (less than = 14 days duration) than those suffering acute diarrhoea only (4.2 versus 3.7 episodes per child per year). Persistent diarrhoea showed a similar seasonal pattern to that of all episodes. Rates of abdominal pain, isolation of Shigella spp and a diagnosis of dysentery were significantly higher in persistent episodes than in acute episodes. Closer follow-up of children during 1986 and 1987, through the recording of all periods of absence of the child from the home, showed that overall diarrhoea incidence rates were little affected when absence was taken into account, but that the incidence of persistent diarrhoea and the proportion of episodes classified as persistent were significantly reduced. The implications of this methodological problem are discussed.     

General practitioners' promotion of healthy life styles: what patients think

Abstract: The study examined the prevalence of cigarette smoking, alcohol consumption, exercising to keep fit and dieting to lose weight among general practice patients, and patients' perceptions of the role of the general practitioner in advising about life style. A cross-sectional survey using a self-administered questionnaire was completed by 13 017 patients aged 18 to 70 years who were attending one of 119 general practitioners from 40 group practices in metropolitan Sydney over a six- to eight-week period. More women than men reported dieting to lose weight, just over half of the men and women were exercising regularly to keep fit, 35 per cent of men and 29 per cent of women reported smoking, and 12 per cent of men and 10 per cent of women were drinking alcohol at levels considered hazardous or harmful. More young people were smoking, drinking hazardously or harmfully, dieting to lose weight and exercising than the older age groups, and their smoking rates exceeded those of the general population. Most patients reported that general practitioners should be interested in their life-style behaviours, particularly smoking. Substantially fewer patients (particularly women who drank excessively) reported receiving advice about their habits. General practitioners were more likely to give advice when smoking and drinking levels were very high. There were discrepancies between patients' expectations of the doctor's role in promoting healthy life styles, and their likelihood of receiving advice. Doctors could reduce the diseases associated with unhealthy practices. Developments in medical training in the 1990s may extend the way they engage in advising on issues of life style.     

Salmonellosis in general practice. Observations of cases and their households in Enfield

Nine hundred and seventeen Salmonella infections in 580 households were confirmed during a laboratory study of diarrhoea in general practices in a large urban area during the years 1953-68. This was an annual incidence of about 2/10,000 population. Salmonellas were found in nearly 2% of new cases of diarrhoea investigated. Plural infections were found in 36% of the households studied and 18% of all contacts examined were shown to be infected. Among these contacts the infection rate was higher for children (24%) than for adults (16%). The duration of infection was longer than 2 months in nearly a quarter of the cases followed up, and intermittent excretion was observed in one-fifth. The commonest serotype was Salmonella typhimurium, but its incidence in the district declined especially after 1964. S. typhimurium infection provoked a severer enteritis but less general symptoms than did other salmonellas. Children were more susceptible than adults to salmonella infection, to illness and to prolonged excretion, but symptoms in index cases were as severe in adults as in children.     

Tuberculosis in Australia: bacteriologically confirmed cases and drug resistance, 1998-1999: report of the Australian Mycobacterium Reference Laboratory Network.

The Australian Mycobacterium Reference Laboratory Network collected and analysed laboratory data on new diagnoses of infection with Mycobacterium tuberculosis complex in 1998 and 1999. Totals of 700 and 760 cases were identified, representing annual reporting rates of 3.7 and 4.0 cases of laboratory confirmed tuberculosis (TB) per 100,000 population in the years 1998 and 1999 respectively. Australia's TB reporting rates have varied little in the past decade, ranging from 3.7 to 4.1 cases per 100,000 population. Reporting rates vary between States, reflecting differences in the distribution of persons in 'high-risk' categories for TB. The male:female ratio decreased to almost 1:1. The median age for males with culture-confirmed TB is in the 45-49 age group; for females, the median is in the 35-39 age group. Pulmonary disease was diagnosed in 63 per cent of cases whereas disease of lymph nodes accounted for 21 per cent of all cases. Children have the lowest rates of culture-confirmed TB; males in the older age groups have the highest rates. Microscopy was positive for 60 per cent of culture-positive sputa, and for approximately 45 per cent of bronchoscopy specimens. The frequency of multi-drug resistance (less than 1%) was slightly lower than in previous years.     

Violent death in a metropolitan county: II. Changing patterns in suicides (1959-1974).

Suicide rates in Cuyahoga County (metropolitan Cleveland) rose from 10.2 in 1958 to 12.5 per 100,000 populations in 1974 (23 per cent increase) with the greatest rise among nonwhite males (from 5.9 to 13.1, or 122 per cent). Increased rates were observed in both the city (19 per cent increase) and suburbs (35 per cent increase). Rates increased among young non-white and white adults of both sexes aged 15--34 years, but decreased slightly among adults aged 65 years and older. These findings are consistent with national trends. Alcohol was present in the blood of one-fourth of the individuals who were "dead on arrival," and at intoxicating levels in 20 per cent. There were increasing percentages of victims with positive blood alcohol and with intoxicating levels during the study period. White male victims in the city had significantly higher frequencies of such findings than their counterparts in the suburbs. The rates of suicide committed by firearms rose among all race-sex groups, with the greatest increase among city nonwhite males (2.1 to 7.7, or 267 per cent). Suicide by chemical agents (roughly one-half being barbiturates) increased in all groups except city nonwhite males, with the greatest increase among white males and suburban white females. Firearms among males and poisoning among females displaced asphyxia as the leading modes of suicide.     

A study of the association between improved sanitation facilities and children's height in Lesotho

The impact of improved sanitation on the anthropometric status of children under 5 years in Lesotho was investigated using children recruited into a case-control study of diarrhoea morbidity. The children's height-for-age Z-scores were used as an indicator of chronic undernutrition. Classifying children as 'stunted' or 'adequately nourished' revealed some evidence of an association between latrine ownership and attained height. After allowing for confounding variables, the odds of stunting were 18 per cent lower among children in households with latrines (95 per cent confidence interval, 36 per cent lower to 3 per cent higher). More powerful analyses, using height-for-age as a continuous outcome variable, revealed that the mean height-for-age Z-score of children from households with a latrine was 0.27 standard deviations higher than that of children from households without a latrine (95 per cent c.i. = 0.12 to 0.42). These results suggest that the anthropometric status of children may be as responsive to improvements in sanitation facilities as diarrhoea morbidity in some settings.     

Laboratory surveillance of invasive pneumococcal disease in Australia, 2003 predicting the future impact of the universal childhood conjugate vaccine program.

A comprehensive invasive pneumococcal disease (IPD) laboratory surveillance program was carried out in Australia in 2003. This program provided data on the prevalence of pneumococcal serotypes and antimicrobial resistance. There were 1,995 isolates tested with 34 per cent (683) from children aged less than five years and 27 per cent (535) from the elderly aged more than 65 years. One thousand eight hundred and sixty were isolates from blood, 79 from CSF and 56 from other sterile sites. In young children, 84 per cent of isolates were a serotype and 92 per cent a serogroup in the 7-valent pneumococcal conjugate vaccine (7vPCV). Of penicillin resistant isolates in children less than five years of age 85 per cent and 98 per cent were a serotype and serogroup in the 7vPCV respectively. When the universal 7vPCV vaccine program in young children is introduced in 2005, a proportion of cases of IPD should also be prevented in young adults (estimated reduction of 54 cases annually) and elderly Australians (an estimated reduction of 110 cases annually) as a result of improved herd immunity. Pneumococcal serotypes with higher rates of penicillin resistance (19F, 14 and 6B) were more prevalent in the elderly than in young children. In contrast, erythromycin resistance was more common in children less than five years of age (24%) compared to the elderly (15%). The predominant serotype with erythromycin resistance in Australia was serotype 14 and thus there is likely to be a major reduction in erythromycin resistance as a result of 7vPCV vaccination. Continued surveillance of pneumococcal serotype distribution and antibiotic susceptibility will be essential in order to identify serotype replacement by non-vaccine serotypes and to monitor the overall impact of current and future vaccine programs on invasive pneumococcal disease in Australia, not only in young children but also in other age groups.     

Campylobacter jejuni as a bacterial cause of diarrhoea in Ile-Ife, NIgeria.

A total of 495 diarrhoea and non-diarrhoea patients whose ages ranged between 5 and 39 years were examined for the presence of Campylobacter jejuni, Salmonella and Shigella species. About 12% of the specimens from diarrhoea patients were positive for Campylobacter jejuni compared with 6% and 10% for Salmonella and Shigella species. In contrast 2%, 0% and 1% of the samples from non-diarrhoea patients were positive for Campylobacter jejuni, Salmonella and Shigella species respectively. Most (62%) of the Campylobacter jejuni from diarrhoea patients were isolated from children under the age of 10 years. This compared with 26% and 37% for Salmonella and Shigella species in this age group. The frequency of isolation of Campylobacter jejuni in diarrhoea patients was highest during the dry months of the year. This study demonstrates the importance of Campylobacter jejuni as a major bacterial cause of diarrhoea in this part of the world.     

Aetiology of diarrhoea in a birth cohort of children aged 0-2 year(s) in rural Mirzapur, Bangladesh

The incidence of aetiology-specific diarrhoea and the pathogenicity of infectious agents in a birth cohort (n=252) in rural Bangladesh were determined. Stool specimens or rectal swabs were collected from diarrhoeal cases over two years and routinely on a monthly basis. Stool samples from children with diarrhoea were compared with stool samples from children without diarrhoea to calculate rates of isolation and pathogenicity of agents. In total, 1750 stool specimens from diarrhoea patients and 5679 stool specimens from children without diarrhoea were tested. An infectious agent was identified in 58% of the stool specimens from diarrhoea patients and 21.6% of the stool specimens from children without diarrhoea. The most commonly-isolated pathogens from all specimens were enterotoxigenic Escherichia coli (ETEC), enteroadherent E. coli, Shigella, Campylobacter jejuni, Giardia, and rotavirus. ETEC (ST and LT-ST toxin), enterotoxigenic Bacteroides fragilis, Shigella, and rotavirus were associated more with disease than with asymptomatic infections. Aetiology-specific infections were associated with acute episodes. The isolated enteropathogens were essentially the same as those found in other tropical rural settings. Enterotoxigenic B. fragilis was also identified as a pathogen. Ongoing vaccine efforts focusing on Shigella, rotavirus, and ETEC would be useful.     

Lack of impact of a water and sanitation intervention on the nutritional status of children in rural Bangladesh

The nutritional impact of a water and sanitation intervention in a rural community of Bangladesh, comprising the provision of handpumps, construction of latrines and hygiene education was assessed. During 3 years, the quarterly anthropometric measures of about 200 children aged 12-35 months from the intervention community were compared with those of a similar number of children from a control area. The interventions reduced the incidence of diarrhoea by 25 per cent among the children less than 5 years of age. There was no significant difference in nutritional status, however, between the two groups of children. Moreover, within the intervention area, indicators of water and latrine use were not significantly related to the children's nutritional status. This suggests that either the obtained reduction of diarrhoea was not large enough to have an impact on nutritional status or that diarrhoea is not an important cause of malnutrition in this community.     

Severe illness in African children with diarrhoea: implications for case management strategies.

To identify clinical disorders associated with severe illness in African children with diarrhoea, we studied a group of under-5-year-olds with diarrhoea who had been brought to a large public hospital in central Cote d''Ivoire. The general condition of children with diarrhoea was assessed and classified according to criteria recommended by WHO, and then used as a nonspecific indicator of severity. Of the 264 children with diarrhoea who were enrolled in the study, 196 had nonsevere illness and 68 severe illness. Children with severe illness were significantly more likely than those with nonsevere illness to be dehydrated (45% versus 11%), moderate-to-severely wasted (47% versus 29%), bacteraemic (26% versus 9%), severely anaemic (haemoglobin level <6 g/dl; 15% versus 6%), have Plasmodium falciparum parasitaemia (27% versus 14%), and have two or more of these five conditions (60% versus 14%). Nontyphoidal Salmonella spp. were present in 68% of the blood isolates but were not associated with seropositivity to human immunodeficiency virus (HIV). The study demonstrates the need for a more comprehensive approach to assessment and management of children with diarrhoea that ensures prompt recognition of bacteraemia, anaemia, wasting and malaria, as well as dehydration. Simple nonspecific observational criteria, such as those recommended by WHO for assessing and classifying general condition, are useful for identifying children with diarrhoea who are at high risk of having life-threatening clinical disorders, and can readily be used by health workers whose clinical training and access to diagnostic laboratory facilities are both limited.     

Pap smears in general practice: a secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991

Abstract: We investigated the characteristics of Australian general practice that predict performance of Pap smears by secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991. Chi–squared analysis identified potential associations between Pap smear rate and patient, doctor and practice variables. Significant associations were examined using logistic regression and generalised estimating equations. Participants were 495 general practitioners who collected information on 113 468 doctor–patient encounters, of which 43 211 encounters involved females aged 18 to 70 years. Pap smear encounters (2449) were identified and classified as patient–requested (62 per cent), diagnostic (5 per cent) or opportunistic (33 per cent). The large difference in the unadjusted Pap smear rates per 100 female encounters for female general practitioners (11.7) and male general practitioners (4.2) required separate analysis by sex of the general practitioner. For male general practitioners, a Pap smear was less likely: as patient age increased; for new patients; for general practitioners with less general practice experience; for general practitioners with no postgraduate qualifications; with metropolitan practice location; and if the practice had more than 25 per cent of patients with English as a second language. For female general practitioners, a Pap smear was less likely: for older known patients; as the age of the general practitioners increased; and for management of fewer problems per 100 encounters. A Pap smear was less likely to be opportunistic: as patient age increased; for general practitioners who were Australian graduates; and for general practitioners with no postgraduate qualifications. Consideration of patient, doctor, and general practice characteristics may facilitate the design of interventions to improve cervical cancer screening.     

Carriage of diarrhoeagenic Escherichia coli by older children and adults in Accra, Ghana

Diarrhoeagenic Escherichia coli (DEC) were sought in stool specimens from 72 adults and children aged over 3 years, who presented with diarrhoea at a hospital in Accra, Ghana, and 72 matched controls. Only diffusely-adherent E. coli were significantly associated with disease in these older individuals (P = 0.029). We additionally tested 53 specimens from infants among whom DEC were collectively associated with disease (P = 0.012). Enteropathogenic, enterotoxigenic and enteroaggregative E. coli, the most commonly isolated pathotypes from infants with diarrhoea, were frequently recovered from healthy adults. Asymptomatic carriage of DEC by older individuals in Accra may place young children at risk for diarrhoea.     

Campylobacter enteritis in The Gambia

In a three-month survey in The Gambia, campylobacters were isolated from 14·3% of 287 patients suffering from diarrhoea and from 4·2% of 383 patients and controls without diarrhoea. The equivalent figures for shigellas were 6·3% and 2·1%, and for salmonella 7·0% and 2·6% respectively. 53 (93%) of the 57 campylobacters were isolated from children less than five years old; none were isolated from indigenous adults (>15 years old). By using two selective media in parallel (Butzler's medium and Skirrow's medium), it was found that the number of isolations was increased by one third over that obtained with either medium alone.It is concluded that in The Gambia the transmission of campylobacters is of high intensity, with most infections occurring in young children, in whom these organisms are an important cause of morbidity and mortality.     

Diarrhoea in close contacts as a risk factor for childhood haemolytic uraemic syndrome. The CPKDRC co-investigators.

To determine whether the risk factors for childhood haemolytic uraemic syndrome (HUS) are similar to risk factors previously reported for Escherichia coli O 157. H7 gastroenteritis, we conducted a case-control study at eight paediatric hospitals in the summer of 1990. Thirty-four consecutive children with HUS were prospectively enrolled; all had diarrhoea and 88% had laboratory evidence of exposure to verotoxin-producing E. coli (VTEC). The 102 controls were otherwise healthy children with minor acute injuries. Parents of all subjects responded to a questionnaire about each child''s exposure to various foods, methods of food preparation, sources of water, travel, and individuals with diarrhoea. Children with HUS were significantly more likely than controls to have had close contact with an individual with diarrhoea in the 2 weeks before the onset of illness (74 v. 29%, P < 0.00001; odds ratio 7.0, 95% CI 2.7-18.5). The onset of diarrhoea in the contacts occurred a median of 6 days (range, 1- > 14 days) before the onset of diarrhoea in the HUS patients. Exposure to undercooked ground meat was not significantly more common in the patients with HUS (15 v. 8%; P = 0.05). These data provide evidence consistent with person-to-person transmission of VTEC in a substantial proportion of episodes of childhood HUS.     

Classification of nutritional status as 'Z score' or per cent of reference median--does it alter mortality prediction in malnourished children?

The objective of the study was to evaluate, using a prospective cohort study, whether classification of nutritional status by 'Z score' or per cent of reference median alters the prediction of death in malnourished children. The subjects were children with diarrhoea requiring hospitalization due to moderate or severe dehydration and/or associated complications. There were 382 participants under 5 years of age, of whom 37 died (cases), 320 were discharged in a satisfactory condition (controls) and 25 left before diarrhoea was completely cured (lost to follow-up--excluded). Rehydrated weight and recumbent length (under 2 years) or standing height were recorded and the three indices (weight for age, height for age and weight for height) derived as both 'Z scores' and per cents of reference National Centre for Health Statistics (NCHS) medians. Logistic regression, sensitivity specificity curves and Zda test for normalized distances were used to compare the relative utility of these two classification methods in identifying children with a high risk of dying. The per cent of reference median and 'Z scores' were highly correlated (r = 0.9540, 0.9787 and 0.9667, respectively). Both methods yielded virtually identical results in predicting death of malnourished children for all the three indices. It was concluded that 'Z score' and per cent classification of nutrition are equally efficient in predicting death of malnourished children.     

A retrospective cohort study of childhood immunisation status in northern Sydney

Abstract: A survey of their children's immunisation status was conducted among mothers of babies from a three-month birth cohort (January to March 1990) in the Northern Sydney Area in 1992. Its aims were to determine the uptake of immunisation in the area, to examine factors associated with immunisation status, and to assess agreement between the parent's reporting of this status and records of councils and general practitioners. Fifty-eight per cent of the questionnaires (1004) were returned. The full immunisation rate was 86 per cent, 14 per cent were partially immunised and only four children had received no immunisations. Between 74 per cent and 82 per cent of vaccinations were on time at two, four and six months; the rate dropped to 21 per cent at 12 months. Logistic regression analysis showed that premature babies are significantly more likely to be fully immunised, whereas children who have had a serious childhood illness, those with a single mother, or whose mothers are more highly educated, are significantly less likely to be fully immunised. There was 60 per cent agreement between the parent's report of immunisation status and a subgroup of 197 council and 82 general practitioner records. Although all councils in the Northern Sydney Area have a reminder system, most immunisations were found to be done in general practices (64 per cent), where reminder systems are not common.     

Prevalence of gastrointestinal disease caused by Clostridium difficile in a university hospital in Hungary

A one-year survey was undertaken to investigate the frequency of diarrhoea caused by Clostridium difficile among patients in a 1200-bed university hospital in Hungary. The VIDAS (bioMérieux) toxin A detection kit was used for screening specimens for the presence of C. difficile toxin. For all other diarrhoeal specimens selected according to special criteria, cytotoxin testing was used to determine the presence of 'free toxin' in the faeces. During the study period, a total of 945 diarrhoeal faecal samples were tested for the presence of C. difficile toxin. Of 375 requested samples, 58 (18.3%) were toxin-A positive. Of the 570 remaining faecal samples selected by the laboratory, 120 (21%) proved to be toxin positive. The results showed that patients from the surgical (33.3%), internal (24%) and haematological (12.8%) wards had the greatest frequency of diarrhoea attributable to C. difficile.