Estimating The Seasonally Varying Effect of Climatic Factors On The District-Level Incidence of Acute Watery Diarrhea Among Under-Five Children of Iran, 2014-2018: A Bayesian Hierarchical Spatiotemporal Model

Background Under-five years old acute watery diarrhea (U5AWD) accounts for most diarrheal diseases' burden due to rotavirus infection. It is claimed that many climatic and socioeconomic factors are associated with U5AWD. However, little information is available about the occurrence of U5AWD in Iran and the adjusted effect of potential determinants. Methods We collected a dataset containing the seasonal numbers of U5AWD cases at the district level of Iran through MOHME. We calculated the district level Standardized Incidence Ratio and Moran's I values to detect the significant clusters of U5AWD over sixteen seasons from 2014 to 2018. In addition, we examined twelve Bayesian hierarchical models to recognize the strongest in predicting the seasonal number of incidents. Results Iran has many hotspots of U5AWD, especially in southeast areas. An extended spatiotemporal model with seasonally varying coefficients and space-time interaction outperformed other models, becoming our proposal in modeling U5AWD. Temperature had a global positive relationship with seasonal U5AWD in districts (IRR: 1.0497, 95% CrI: 1.0254–1.0748), due to its varying effects in winter (IRR: 1.0877, 95% CrI: 1.0408–1.1375) and fall (IRR: 1.0866, 95% CrI: 1.0405–1.1357) seasons. Also, elevation (IRR: 0.9997, 95% CrI: 0.9996–0.9998), piped drinking water (IRR: 0.9948, 95% CrI: 0.9933–0.9964), public sewerage network (IRR: 0.9965, 95% CrI: 0.9938–0.9992), years of schooling (IRR: 0.9649, 95% CrI: 0.944–0.9862), Infrastructure-to-Household Size Ratio (IRR: 0.9903, 95% CrI: 0.986–0.9946), wealth index (IRR: 0.9502, 95% CrI: 0.9231–0.9781) and urbanization (IRR: 0.9919, 95% CrI: 0.9893–0.9944) of districts were negatively associated with seasonal U5AWD incidence. Conclusions The development of specific alert systems could be a strategy to predict high-risk areas of U5AWD using climatic inputs. Also, the study anticipates a higher incidence of U5AWD in districts with weaker hygiene and socioeconomic status. Therefore, policymakers should take appropriate preventive actions in such areas.

A Comparative Evaluation on the effect of Zinc-Probiotic combination versus Zinc alone therapy in children (3month-5year) with acute watery diarrhea attending the outpatient clinic of Sub-District hospital, Uttarakhand

Background: Diarrhea is the major cause of morbidity and mortality among children worldwide.Various studies were done on the role of zinc therapy and probiotic therapy in reducing the durationand severity of acute watery diarrhea. This study aimed to compare the effect of Zinc –probioticcombination versus Zinc only therapy in acute watery diarrhea in pediatric patients. Material andMethods: This was an open, randomized control trial in the pediatric outpatient department of Sub-District Female Hospital, Haldwani (Uttarakhand), from June 2020 till August 2020 for three months.Total 104 children aged six months to 5 years with acute diarrhea who met the inclusion criteriawere enrolled and divided into 52 patients each. 1stGroup A (n=52) received Zinc-Probioticscombination therapy, and 2ndGroup B (n=52) received Zinc only. Measurement of disease severitywas based on the frequency of diarrhea (times/day) and duration of diarrhea (hours) after initialdrug consumption. The resolution was assessed in mean remission time (time required to form solidstool from watery stool).Result: Among the study population in group A, 62% were male, 38%were female, and in group B, 65% were male & 35% were female. Male predominance was observedin both groups. The mean frequency of diarrhea before treatment in Group A was 7.46 ± 4.1times/day as compared to 6.69 ± 3.6 times/day in Group B. Mean duration of diarrhea in Group Awas 53.5 ± 30.5 hours as compared to 57.6 ± 34.3 hours in Group B. Conclusion: Combinationtherapy was more effective than Zinc only therapy in early remission and resolution of acute waterydiarrhea in children.

A retrospective review on antibiotic use in acute watery diarrhea in children in a tertiary care hospital of Karachi, Pakistan

Introduction Responsible for at least one in nine pediatric deaths, diarrheal diseases are the leading, global cause of death. Further abetted by improper antibiotic use in a hospital setting, children with acute watery diarrhea can see prolonged hospital stays, and unwanted adverse effects such as antibiotic resistance. Hence, this study is aimed to identify the association between antibiotic usage for the treatment of acute watery diarrhea in children, and the impact this line of management has on the duration of their hospital stay. Methods A retrospective review was conducted at the department of Pediatric of Aga Khan University Hospital (AKUH) in Karachi. A total of 305 records of children aged 6 months to 5 years who were admitted with a diagnosis of acute watery diarrhea from June 2017 –December 2018 was screened, of which 175 fulfilled the eligibility criteria. A predesigned questionnaire was used to collect demographic information, comorbidities, and clinical features, severity of dehydration, clinical examination, treatment received, and laboratory investigations. The primary outcome of this study was the length of hospital stay measured against the number of hours a child stayed in hospital for treatment of acute watery diarrhea. The statistical analysis was carried out using STATA version 14 to reach conclusive results. Results 175 patients presented with acute watery diarrhea, out of which 106 (60.6%) did not receive antibiotics. The median (IQR) age of the group that did not receive antibiotics was 12.0 (12.0) months compared to 15.0 (12.0) months for the group that did receive antibiotics. In both groups, there were more males than females, less than 15% of the patients were severely malnourished (WHZ score -3SD) and less than 10% of the patients were severely dehydrated. The median (IQR) length of hospital stay (hours) was 32.0 (19.0) respectively for the group that did not receive antibiotic and 41.0 (32.0) for the group that did receive antibiotic therapy. The expected length of hospital stay for the group that received antibiotic therapy was 0.22 hours higher than the group that did not. Finally, as compared to females, hospital stay for males was longer by 0.25 hours. Conclusion In conclusion, antibiotic use was associated with a prolonged hospital stay in children with acute watery diarrhea as compared to children who did not receive antibiotics. Large scale robust prospective studies are needed to establish this association using this observational data.

Prevalence of Antibiotic Use and Household Water-Sanitation Risk Factors of Acute Watery Diarrhea Among Children <5 Years: A Retrospective Analysis of Multicounty Health Survey Data, 2006-2018

A total of 12,69,944 under five years Childs were included in this study among them 1,80,067 Children were acute watery diarrhea (AWD) and 19,502 Children were bloody diarrhea respectively. Among them, 47,755 Childs was taken antibiotic treatment for AWD. The overall prevalence of acute watery diarrhea ~ 14% (prevalence = 0.142; 95% CI = 0.141, 0.142). On the other hand the prevalence of bloody diarrhea ~ 2% (prevalence = 0.015; 95% CI = 0.015, 0.016). The prevalence of antibiotic treatment for AWD was ~ 27% (prevalence = 0.27, 95% CI = 0.26, 0.27) among the under five years old children in DH survey regions in the world. The prevalence of acute watery diarrhea was higher ~ 17% (prevalence = 0.17, 95% CI = 0.16, 0.17) in the Latin America DHS survey region. The minimum prevalence of AWD was almost equal between South East Asia and Central Asia DHS survey regions ~ 12% (prevalence = 0.12, 95% CI = 0.11, 0.12) and ~ 12% (prevalence = 0.12, 95% CI = 0.10, 0.13) respectively. On the other hand the prevalence of AWD between Europe and West North and Central Africa DHS survey regions ~ 16% (prevalence = 0.16, 95% CI = 0.15, 0.16) and ~ 15% (prevalence = 0.15, 95% CI = 0.14, 0.15) correspondingly. In the central Asia of 15,089 under five Childs were included in the survey. Among them 1,748 Children were AWD and 967 Childs had taken antibiotic treatment for AWD. The highest prevalence of antibiotic use for AWD in Central Asia ~ 55% (prevalence=(967/1748) = 0.55, 95% CI = 0.52, 0.59) and Europe DH survey region ~ 44% (prevalence=(5483/12502) = 0.44, 95% CI = 0.43, 0.45). The lowest prevalence of antibiotic use for under five Child AWD was ~ 23% (prevalence=(11918/51328) = 0.23, 95% CI = 0.22, 0.24) in the DH survey region South East Asia. On the other hand the DH survey region Latin America and West North and Central Africa region the prevalence of antibiotic use for AWD were ~ 30% (prevalence=(7887/26396) = 0.30, 95% CI = 0.29, 0.31) and ~ 24% (prevalence=(21500/88093) = 0.24, 95% CI = 0.23, 0.24). The southeast Asia DH survey region countries DHS 2007 (Bangladesh), DHS 2014 and 2010 (Cambodia), DHS 2017 and 2012 (Indonesia), DHS 2009 (Maldives), DHS 2015–2016 (Myanmar), DHS 2012–2013 (Pakistan), DHS 2017 and 2013 (Philippines), and DHS 2009–2010 (Timor-Leste) were higher risks of AWD for drinking unimproved water sources. The prevalence of antibiotic use for u5c AWD was shown the highest prevalence in DHS 2007 (~ 44%), DHS 2012 (~ 49%), DHS 2016 (~ 40%), and DHS 2017 (~ 65%) from DH survey 2006 to 2018 in South East & Central Asia. The linear trend analysis showed an upward trend for using antibiotic of AWD in the South East & Central Asia DH survey region.

Fecal Microbiota Functional Gene Effects Related to Single-Dose Antibiotic Treatment of Travelers’ Diarrhea

Background Travelers’ diarrhea (TD) is common among military personnel deployed to tropical and sub-tropical regions. It remains unclear how TD and subsequent antibiotic treatment impact the resident microflora within the gut, especially given increased prevalence of antibiotic resistance among enteric pathogens and acquisition of multidrug-resistant organisms. We examined functional properties of the fecal microflora in response to TD, along with subsequent antibiotic treatment. Methods Fecal samples from US and UK military service members deployed to Djibouti, Kenya, and Honduras that presented with acute watery diarrhea were collected. A sample was collected at acute presentation to the clinic (day 0, prior to antibiotics), as well as 7 and/or 21 days following single dose of antibiotics (azithromycin (500 mg), levofloxacin (500 mg), or rifaximin (1650 mg), all with loperamide). Each stool sample underwent culture and TaqMan RT-PCR analyses for pathogen and antibiotic resistance gene detection. Purified DNA from each sample was analyzed using the HumiChip3.1 functional gene array. Results In total, 108 day 1 samples, 50 day 7 samples, and 94 day 21 samples were available for analysis from 119 subjects. Geographic location and disease severity were associated with distinct functional compositions of fecal samples. There were no overt functional differences between pre- and post-antibiotic treatment samples, nor was there increased acquisition of antibiotic resistance determinants for any of the antibiotic regimens. Conclusions These results indicate that single-dose antibiotic regimens may not drastically alter the functional or antibiotic resistance composition of fecal microflora, which should inform clinical practice guidelines and antimicrobial stewardship.

EFFICACY OF SACCHAROMYCES BOULARDII IN THE MANAGEMENT OF ACUTE WATERY DIARRHEA

Objective: To determine the Efficacy of probiotic (saccharomyces boulardii) in children (2 months to 5 years) with acute watery diarrhea. Study Design: Comparative cross sectional study. Place and Duration of Study: This study was carried out in the department of pediatrics, Combined Military Hospital, Quetta, from Jan 2017 to Jun 2018. Methodology: All children (2 months to 5 years) with acute watery diarrhea presenting within 24 hour of illness with no dehydration and some dehydration were enrolled and divided into two groups, study group and control group. Efficacy was assessed by reduced frequency of stools(less than 3 per day) and duration during the study period. Results: Mean age of the children in probiotic saccharomyces boulardii group was 3.42 ± 1.36 years, while mean age in control group was 3.91 ± 1.16 years (p-value 0.002). Significant difference was also observed in duration of stool and frequency of stool at day 1-5 (p-value <0.05). Statistically significant difference was observed among children in probiotic sacchramyces boulardii group 114 (53%) as compared to controls 101 (47%) (p-value 0.021). Conclusion: The Efficacy of probiotic (saccrharomyces boulardii) was found satisfactory in children (2 months to 5 years) with acute watery diarrhea. In children with acute watery diarrhea saccrharomyces boulardii may be recommended for better outcome.

Prevalence of antibiotic use and household water-sanitation risk factors of acute watery diarrhea among children <5 years: retrospective analysis of multicounty health survey data, 2006-2018

A total 12,69,944 under five year Childs were included in this study among them 1,80,067 Childs were acute watery diarrhea (AWD) and 19,502 Childs were bloody diarrhea respectively. Among them 47,755 Childs were taken antibiotic treatment for AWD. The overall prevalence of acute watery diarrhea ~ 14% (prevalence = 0.142; 95% CI = 0.141, 0.142). On the other hand the prevalence of bloody diarrhea ~ 2% (prevalence = 0.015; 95% CI = 0.015, 0.016). The prevalence of antibiotic treatment for AWD was ~ 27% (prevalence = 0.27, 95% CI = 0.26, 0.27) among the under five years old children in DH survey regions in the world. The prevalence of acute watery diarrhea was higher ~ 17% (prevalence = 0.17, 95% CI = 0.16, 0.17) in the Latin America DHS survey region. The minimum prevalence of AWD was almost equal between South East Asia and Central Asia DHS survey regions ~ 12% (prevalence = 0.12, 95% CI = 0.11, 0.12) and ~ 12% (prevalence = 0.12, 95% CI = 0.10, 0.13) respectively. On the other hand the prevalence of AWD between Europe and West North and Central Africa DHS survey regions ~ 16% (prevalence = 0.16, 95% CI = 0.15, 0.16) and ~ 15% (prevalence = 0.15, 95% CI = 0.14, 0.15) correspondingly. In the central Asia of 15,089 under five Childs were included in the survey. Among them 1,748 Childs were AWD and 967 Childs had taken antibiotic treatment for AWD. The highest prevalence of antibiotic use for AWD in Central Asia ~ 55% (prevalence=(967/1748) = 0.55, 95% CI = 0.52, 0.59) and Europe DH survey region ~ 44% (prevalence=(5483/12502) = 0.44, 95% CI = 0.43, 0.45). The lowest prevalence of antibiotic use for under five Child AWD was ~ 23% (prevalence=(11918/51328) = 0.23, 95% CI = 0.22, 0.24) in the DH survey region South East Asia. On the other hand the DH survey region Latin America and West North and Central Africa region the prevalence of antibiotic use for AWD were ~ 30% (prevalence=(7887/26396) = 0.30, 95% CI = 0.29, 0.31) and ~ 24% (prevalence=(21500/88093) = 0.24, 95% CI = 0.23, 0.24). The South East Asia DH survey region countries DHS 2007 (Bangladesh), DHS 2014 and 2010 (Cambodia), DHS 2017 and 2012 (Indonesia), DHS 2009 (Maldives), DHS 2015–2016 (Myanmar), DHS 2012–2013 (Pakistan), DHS 2017 and 2013 (Philippines), and DHS 2009–2010 (Timor-Leste) were higher risk of AWD for drinking unimproved water sources. The prevalence of antibiotic use for u5c AWD was shown highest prevalence in DHS 2007 (~ 44%), DHS 2012 (~ 49%), DHS 2016 (~ 40%), and DHS 2017 (~ 65%) from DH survey 2006 to 2018 in South East & Central Asia. The linear trend analysis showed that upward trend for using antibiotic of AWD in the South East & Central Asia DH survey region.

Lactose intolerance in malnutrition: Do we guidelines?

Objective: To determine the frequency of lactose intolerance in malnourished children presenting with acute watery diarrhea. Study Design: Cross Sectional study. Setting: Department of Pediatrics at The Children’s Hospital & the Institute of Child Health. Period: 20th December 2015 till 20th June 2016. Material & Methods: A total of 225 children fulfilling inclusion criteria were selected. Stool samples were tested for reducing substances after informed consent from parents. Approval from Ethical Committee was taken. Data was entered and analyzed through SPSS 2.0. Results: Out of total 225 patients with age 3 months to 2 years (mean age 13.41±5.93 months), 112 (49.8%) were males and 113 (50.2%) were females. Overall lactose intolerance was observed in 57 (25.3%) patients, out of which, 27 (24.1%) were males and 30 (26.5%) were females. Total of 129 (57.3%) had low socio-economic status out of which 35 (27.1%) had lactose intolerance. Conclusion: In these malnourished children with acute watery diarrhea, lactose intolerance is high and local guidelines are necessary for proper screening and management.

Cholera Outbreak in Hadhramout, Yemen: The Epidemiological Weeks 2019

Background and aims: Cholera is a disease of acute watery diarrhea caused by Vibrio cholerae usually transmitted through contaminated water. In this study, we collected and analyzed the related epidemiological data to determine cholera outbreak in Hadhramout, Yemen during the disease epidemic in 2019. Methods: A cross-sectional study was conducted according to screening rapid diagnostic and confirmatory laboratory culture testing methods for diagnosing clinically cholera cases. Results: Suspected cholera cases were tested by rapid diagnostic test (RDT) and 399 (50.5%) out of 794 cases were determined positive, and 76(9.6%) of them were confirmed by laboratory culture test (LCT) with statistically significant difference. Serotype V. cholerae O1 was also detected in patients’ diarrhea. Females were the most affected by the disease manifested in 201 (25.3%) and 43 (5.4%) when tested by RDT and LCT, respectively, with no statistically significant difference. The highest proportion of cholera cases (224) were reported in the age group less than 15 years (56.1%) with statistically significant difference when tested by RDT, and 45(13.3%) when tested by LCT with insignificant statistics difference. Hajr directorate was revealed to be the most affected with 242 (30.47%) followed by Mukalla city directorate with 108 (13.60%) when the cases were tested by RDT; while Hajr and Mukalla city directorates reported 55 (7.0%) and 15 (2.0%), respectively, when it was confirmed by LCT with a statistically significant difference. Conclusion: Severe cholera outbreak occurred during the epidemiological weeks in 2019 in Hadhramout coast. V. cholerae O1 serotype was the causative agent of cholera. Females and age group less than 15 years were the most affected by the disease. Hajr and Mukalla city directorates reported serious outbreak cholera cases.

Role of Racecadotril in Children with Acute Diarrhea

Background: Diarrhea is a leading cause of illness and death among children in developing countries. Racecadotril (acetorphan), an enkephalinase inhibitor with antisecretory and anti-diarrheal actions, is an effective and safe treatment for acute diarrhea in adults and children. Objectives: The objective of this study is to evaluate the efficacy and tolerability of racecadotril as a treatment of acute diarrhea in children. Methods: This double-blind, randomized controlled clinical trial was conducted in Dr. MR Khan Children Hospital & Institute of Child Health over 1 year (June 2017- May 2018). The study was approved by the ethical committee of the institute. The efficacy and tolerability of racecadotril (1.5 mg/kg) administered orally 3 times daily) as adjuvant therapy to oral rehydration or intravenous fluid were compared with those of placebo in 40 children aged 3 months to 60 months of children who had acute diarrhea. Results: During the first 72 hours of treatment, patients receiving racecadotril had a significantly lower stool output (grams per hour) than those receiving placebo. The mean (±SE) 72-hours stool output was 54.75± 12.92 g per kilogram in the racecadotril group and 152.50±37.64 g per kilogram in the placebo group (p<0.001). The number of purging is significantly reduced in the racecadotril group than the placebo group (11.95±2.41 Vs 14.85±1.95, p= 0.000) on third day of admission. The duration of hospital stay is significantly lower in the racecadotril group than the placebo group (73.30±23.44 vs. 177.30±25.8. p= 0.000) group. Racecadotril was well tolerated; only 3 patients taking racecadotril had adverse effects like vomiting and 2 patients had hypokalaemia and 3 patients in the placebo group developed vomiting and 1patient developed hypokalaemia which all are mild and transient. Conclusion: In young children with acute watery diarrhea, racecadotril is an effective and safe treatment along with rehydration therapy. DS (Child) H J 2020; 36(1) : 8-13