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Objective: To report a case of delayed-onset chronic diarrhea, anorexia, and weight loss possibly complicating the use of ticlopidine., Case Summary: A 48-year-old white man presented with unremitting diarrhea associated with anorexia and marked weight loss. His history was significant for transient ischemic attack, resistant hypertension, homocystinemia, and chronic renal insufficiency. The patient had tolerated ticlopidine therapy for 2 years without problems, and there had been no changes in his drug regimen for several months. No abnormality was found on detailed digestive system evaluation and all symptoms and signs promptly resolved after ticlopidine therapy was discontinued., Discussion: The occurrence of diarrhea early during ticlopidine therapy should make the clinician consider the drug as the most likely cause. However, the appearance of chronic diarrhea, anorexia and weight loss years after a patient had tolerated the drug is less typical for ticlopidine. In such situations, if no other cause can be identified, cautious withdrawals of the drug should be considered. We believe that all the patient's symptoms reported here were likely due to ticlopidine., Conclusions: Clinicians should be aware that the gastrointestinal adverse effects of ticlopidine may surface years after therapy is begun. The cause of ticlopidine-induced diarrhea remains unknown.

Rural women were involved in a water and sanitation project (WSS) in which health impacts were compared between children in two areas: intervention and comparison areas. In intervention area people were provided with handpumps, latrines and hygiene education, whereas, in the comparison area, people did not receive these project inputs. In the intervention area women were directly involved in the site selection of handpumps and latrines, their installation, construction, and maintenance. Observations on women's involvement and their performances in the intervention area are presented. About 89% of the pumps maintained by women (n = 30), and 86% of those maintained by project workers (n = 49) were found to be in good working condition. Women supervised the construction of all 754 latrines, fenced 58% of the projects-supported latrines (n = 268) and emptied the pits of 65% of the 276 filled-up latrines. Socio-cultural factors were not barriers to women's involvement and performance. The findings have policy implications for effective involvement of rural women towards the development of sustainable WSS programs.

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 defined as acute (< 14 d) and persistent (> or = 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.

A nationwide survey was undertaken in April 1987 in the Kingdom of Saudi Arabia and a questionnaire was administered to 1,656 mothers having children less than 5-years of age. The number of mothers with 1-3 children less than 5-years old was 1,535 and with more than 3 children was 129. The literacy rate of fathers was 70% and of mothers was 26.3%. Incidence of diarrhoea was significantly associated with fathers' occupation (p = 0.0011) but no significant association was found between the incidence of diarrhoea and parents' education.

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.

This study examined the role of food and water contamination in a health impact evaluation of a water and sanitation intervention project. Although lower diarrhoea rates were found in the improved area no consistent difference in food and water contamination was observed between areas. Furthermore, no relationship was found between contamination and diarrhoea in either area, even after controlling for the nutritional status of children. These results imply that other vehicles of transmission might be more important than food and water in diarrhoeal transmission. The focus of interventions should therefore be on changing behaviours to improve overall hygiene.

A diarrhea-producing toxin from a blue-green alga, Microcystis aeruginosa Kützing, was obtained from standing laboratory cultures. The non-dialyzable fraction of the lysate from whole cells produced fluid accumulation in the ligated small intestinal loops in guinea pigs.

Eighty mothers whose children had measles in the past month were interviewed for beliefs and practices related to the management of measles and measles associated diarrhoea. Beliefs and practices about diarrhoea, associated with measles are described. Diarrhoea during and after measles was considered beneficial by mothers, who believed it helped to flush out impurities from the body. Paradoxically ORS was not used because of an erroneous idea that ORS would stop diarrhoea. Informing mothers that ORS will not stop diarrhoea, but will help in flushing out the impurities, could enhance ORS use, reducing morbidity and mortality. The prevalent belief, that measles patients must be kept in a clean environment is useful and should be encouraged. Other beliefs and practices to hasten the eruption are neutral, but since they encourage cleanliness and isolation, need not be discouraged.

Vibrio mimicus has recently been isolated from aquatic environments of Bangladesh. A total of 125 of 300 environmental isolates, representing various biotypes, and 19 human isolates were tested for enteropathogenicity by using several models. Less than 1% of the environmental isolates and slightly more than 10% of the clinical isolates produced cholera toxin-like toxin. A significant percentage of the environmental isolates (25%) and of the human isolates (74%) induced fluid accumulation in ligated rabbit ileal loops. One environmental strain produced heat-stable toxin-like enterotoxin, whereas all of the human isolates did not. V. mimicus strains were divided into the following three groups on the basis of their activity in various toxin assays: (i) organisms which produce a heat-labile enterotoxin immunobiologically similar to cholera toxin, (ii) organisms which produce a heat-stable enterotoxin-like toxin, and (iii) organisms whose whole-cell cultures have some activity characteristic of heat-labile toxin (e.g., fluid accumulation in ligated rabbit ileal loops and positive permeability factor) but are not positive by the GM1 enzyme-linked immunosorbent assay. One isolate from this group was able to elicit these results with cell-free culture filtrates. There was no correlation of biotype with toxic activity of V. mimicus isolates.

To combat dehydration from diarrhoea in Shamlapur, a village of 7021 people, multiple community-based points were set up by trained volunteers for the distribution of glucose-electrolyte oral rehydration salt (ORS) packets. The comparable adjoining village, Bordil, with a population of 3888, obtained its supply of ORS from Shamlapur. Surveilance for 2 years showed that although diarrhoeal attack-rates were equal, consumption of ORS after diarrhoea was 80% in Shamlapur and 38% in Bordil. There were 8 deaths in Shamlapur caused by diarrhoea and 23 in Bordil, showing an overall case fatality-rate of 0.5% and 2.4%, respectively, and a diarrhoeal mortality-rate per 1000 population of 0.6 and 2.9, respectively. The observation indicated that although it may not be possible to reduce diarrhoeal attack-rates, easy availability of rehydration solution and its early use after village-based training may save many lives, particularly those of children.

Many community based studies of diarrhoea in the developing world employ face-to-face interviews to obtain diarrhoeal histories. An alternative recording device that preserved the accuracy but avoided the expense and time commitment of the interview would be extremely valuable. To evaluate the comparability of episodes of diarrhoea obtained from a home-maintained two-week calendar with those histories given in response to a two-week health recall interview in a largely uneducated population, we studied approximately 1500 families for six months in Dhaka, Bangladesh. The diarrhoea records obtained for children by the two methods were highly comparable (Kappa value 0.83). The comparability was not impaired either by lack of maternal education nor by increased numbers of children in the household. We conclude that the two-week home maintained diarrhoea calendar offers comparable results with the two-week recall and in certain situations could be a useful substitute.

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.

Growth of rural Bangladeshi children aged 6-35 months was examined in relation to the history of diarrhoea in 1772 3-month intervals. Weight gain and linear growth were lower in intervals with a history of diarrhoea than in intervals without diarrhoea. However, comparison of weight and height gains in intervals during which diarrhoea occurred at the beginning or at the end showed that after non-bloody diarrhoeas children catch up and that deficits in weight gain and linear growth were no longer apparent a few weeks later. These findings suggest that the effect of diarrhoea on growth is transient and that efforts to control diarrhoea are unlikely to improve children's nutritional status in the long term.

To study the interaction between diarrhoea and malnutrition, an average of 300 children aged 5-24 months were followed from January 1981 to January 1983 in Teknaf, Bangladesh. Diarrhoea episodes, differentiated according to stool appearance, were recorded weekly while weight and height measurements were taken every 6 months. Results showed no relationship between the nutritional indicators and diarrhoea incidence recorded within 60 d after anthropometric assessment. However, the duration of dysentery was significantly longer in the severely malnourished children who were stunted but not for those wasted. Although many children with watery diarrhoea had episodes of long duration, these were not associated with any nutritional indicator. We conclude that the key factors in this interaction are the invasive type of pathogen and chronic malnutrition.

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.

Attendance rates at a diarrhea clinic were monitored in a defined population in rural Bangladesh. Weekly home visits were also carried out to determine diarrheal attacks in communities within six miles of the clinic. Within the first one mile radius, 90 per cent of diarrheal cases came to the clinic for treatment. At two miles the attendance fell to 70 per cent for males and 40 per cent for females. On an average, the greater the distance to the clinic, the more severe was the degree of dehydration on presentation, requiring more frequent use of intravenous fluid. Mortality secondary to diarrhea was significantly reduced only within a two-mile radius of the clinic.