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Background: The exposure patterns across ethnic groups are unclear for stomach bugs that cause self-limiting symptoms, significantly burdening UK health-care services and the economy. This study seeks to fill this gap by exploring how inequalities arise in managing stomach bugs in UK ethnic groups., Methods: A qualitative study using semi-structured interviews was undertaken. Ethics approval was given by the University of Liverpool, and data were collected by IZ over 11 months from July 26, 2022, and May 26, 2023. Purposive sampling was used to recruit a general UK population sample (excluding health-care professionals) who were adults, partners, and parents, from an ethnic minority group, with recent diarrhoea, vomiting, or a stomach bug over the past 6 months. Recruitment was conducted through community gatekeepers using flyers. Participants were interviewed in person or virtually and gave written informed consent. An incentive of an Amazon voucher of £10 was imbursed to participants for their time. Interviews were audio-recorded using a password-protected digital recorder, transcribed verbatim, and analysed using reflexive thematic analysis., Findings: 36 interviews (median age 31·5 years) were conducted with 11 women of Pakistani (n=6), Bangladeshi (n=2), Indian (n=2) and Arab ethnicity (n=1), and 25 men of Black (n=22), Pakistani (n=2), and Indian (n=1) ethnicity. This sample enabled an exploration of within-ethnic group experiences of stomach bugs in participants who self-defined their age, sex, and ethnicity. Themes such as managing food preparation (n=16), travel abroad (n=17), and personal cleanliness (n=3) were consistently reported across transcripts. The findings corroborate existing literature that there are more similarities than divergences in the management of stomach bugs across ethnic groups, such as the burden of care disproportionately affecting women and using over-the-counter medication to manage symptoms., Interpretation: We do not know if the impact of these experiences across ethnic groups is entirely representative of the broader ethnic categories (ie, Asian vs Indian, Pakistani, and Bangladeshi) they belong to or if there are inequalities in their impact on ethnic groups living in different circumstances (ie, UK born vs migrant)., Funding: National Institute for Health and Care Research (NIHR)., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The patient is an otherwise healthy two-month-old boy who received the recommended vaccinations for his age group, which included the rotavirus pentavalent vaccine (RV5; RotaTeq) at his two-month well child visit. Three days later, he developed prolonged non-bloody diarrhea and was found to have persistently positive rotavirus antigen in his stool. Subsequent workup revealed mild defects in his functional T-cell immunocompetence. Genetic testing was obtained through the Invitae panel and was negative for hereditary forms of primary immunodeficiencies. The rotavirus antigen was found to have cleared from his stool around four months after receiving the RV5. Unfortunately, the source of the rotavirus infection was unable to be determined. The caregivers had misconceptions about the vaccine and the child's immune system function which led to refusal of any further vaccinations. Healthcare providers should strive to develop honest and respectful relationships with parents to have thoughtful dialogues regarding vaccine safety and efficacy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: There are few studies of the incidence of health problems among travelers to Southeast Asia. The current study sought to determine the incidence of self-reported health problems among travelers visiting the region., Methods: A prospective questionnaire-based study was conducted among travelers from high-income countries who visited Southeast Asia. Participants were enrolled at time of their pre-travel visit at Mahidol University, Bangkok, Thailand. Travelers were prospectively followed by self-administered questionnaires 2 weeks after arrival, upon return to their home country and 2 weeks after return., Results: During January 2018-February 2019, 359 travelers were enrolled in Bangkok, Thailand, and the first questionnaire was administered. Follow-up questionnaires were returned by 191, 96 and 64 participants 2 weeks later, at the end of the trip and 2 weeks after return, respectively. A total of 6094 travel days were included in the final analysis. The incidence of acute diarrhea per month per 1000 travelers was 217 [95% confidence interval (CI), 189-248] episodes; skin problems, 197 (95% CI, 170-227); respiratory symptoms, 133 (95% CI, 111-158); fever, 49 (95% CI, 36-65); and potential rabies exposure, 34 (95% CI, 24-48). The incidence of acute diarrhea episodes per month per 1000 travelers was significantly higher during the first 2 weeks of travel compared with subsequent weeks of travel: 325 (95% CI, 291-362) vs 132 (95% CI, 110-1157) (P < 0.05). The incidence of outpatient visits and hospitalizations per month per 1000 travelers was 49 (95% CI, 36-65) and 5 (95% CI, 2-10), respectively., Conclusions: In this prospective cohort study we observed substantial burden of acute diarrhea and skin and respiratory symptoms among travelers to Southeast Asia. The higher incidence of diarrhea in the first 2 weeks of travel should be further investigated., (© International Society of Travel Medicine 2019. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Background: Travelers' diarrhea (TD) is frequently encountered in people traveling from high-income to low-income countries; however, its epidemiology in those traveling between high-income countries is not known., Objectives: To evaluate the incidence of diarrhea in North American students relocating to Israel., Methods: A retrospective cohort study involving medical students from the United States and Canada relocating to Israel was conducted. Students who relocated to Israel during 2010-2016 were contacted by email to participate in an anonymous survey. Data included demographic information as well as occurrence, timing, duration, and outcome of diarrhea after relocation., Results: Ninety-seven students participated in the survey. Most (93.7%) students relocated from the United States or Canada. The period-prevalence of diarrhea was 69.1%. The incidence of diarrhea declined from 34.8 cases per 100 student-months during the first month after relocation to 1.3 cases per 100 student-months after 1 year. The duration of diarrhea was up to 1 week in 72.7%. Students who reported diarrhea were younger than students who did not (mean age 24.0 ± 2.2 and 28.4 ± 1.8 years, respectively, P < 0.001). No other demographic parameter was significantly associated with a higher likelihood of diarrhea., Conclusions: A high proportion of North American medical students relocating to Israel reported diarrhea with clinical and epidemiological features similar to classic TD. Further studies are needed to elucidate the causative agents of TD in Israel.

Background: S. Typhimurium was the dominant serovar in an infant in Fuzhou, China. There have been few comprehensive studies on Salmonella typhimurium in infants in China., Methods: We conducted a retrospective study on 30 Salmonella typhimurium from 3,200 fecal samples of infants with acute diarrhea from 2015 to 2017. Thirty S. Typhimurium strains were tested for antimicrobial susceptibility and characterized for virulence genes. Pulsed-field gel electrophoresis (PFGE) was also applied for comparison of genetic relatedness., Results: All of the strains harbored misL, orfL, pipD, prgH, sifA, sopB, sitC, spiC, and invA genes. The other three gene distributions in the strains are different. Strains subtyped into 4 virulotypes (VP1-VP4), the most common virulence profile was VP3, accounting for 63.3% of the strains. The resistance to ciprofloxacin and ceftriaxone was 26.7%. The proportion of MDR isolates is approximately 90.0%. Sixteen different antimicrobial resistance patterns were observed and the most frequent resistance type was antibiotype 13 (resistance to streptomycin, tetracycline, amoxicillin), occurring in 43.3% of the isolates. Regarding PFGE, 30 isolates of S. Typhimurium showed genetic diversity, while no predominant PFGE patterns were observed in S. Typhimurium. Moreover, no correlation between virulence profiles or antibiotic patterns and PFGE clusters was observed. With one exception, VP1 which harbors pefA showed more diversity than the other virulence profiles among PFGE profiles., Conclusions: Our study provided valuable information on virulence gene content, antibiotic resistance, and genetic diversity of S. Typhimurium isolated from infant with acute diarrhea in Fuzhou, China.

Objectives: No studies to date estimate the prevalence of chronic diarrhea in the United States using the Bristol stool form scale (BSFS). This study aims to report the prevalence and associated factors of chronic diarrhea using BSFS scores in a nationally representative sample of US adults., Methods: We identified 5,246 adult participants (age ≥20 years) who completed the bowel health questionnaire in the National Health and Nutrition Examination Survey 2009-2010 data set. Chronic diarrhea was defined as type 6 or 7 rating on the BSFS (mushy or liquid consistency) as the "usual or the most common stool type." Co-variables included age, race, education, poverty income ratio, body mass index, number of medications, feeling depressed, physical activity, and dietary intake. Prevalence estimates and prevalence odds ratios (PORs) were analyzed in adjusted multivariable models using appropriate sampling weights., Results: We found a prevalence of chronic diarrhea of 6.6% (95% confidence interval (CI) 5.8, 7.4) in the nationally representative data set. High daily carbohydrate intake (POR 1.56, 95% CI 1.02, 2.40), obesity (POR 2.04, 95% CI 1.44, 2.89), feeling depressed (POR 1.84, 95% CI 1.21, 2.80), older age (POR 1.02, 95% CI 1.01, 1.02), and female sex (POR 1.68, 95% CI 1.28, 2.21) were positively correlated with chronic diarrhea. Non-Hispanic White race (POR 0.49, 95% CI 0.29, 0.81) and higher education (POR 0.60, 95% CI 0.43, 0.83) were negatively correlated with chronic diarrhea., Conclusions: In a nationally representative sample of the US adults, the prevalence of chronic diarrhea was 6.6%. We identified demographic, lifestyle, and dietary factors associated with chronic diarrhea.

Background: The number of international travellers visiting Myanmar increases each year. However, information about pre-travel preparation and incidence of health problems among these travellers is limited., Methods: This cross-sectional study was conducted at three international airports in Thailand. Travellers returning from Myanmar completed questionnaires querying demographic profile, pre-travel health preparations and health problems during their stay in Myanmar., Results: From March 2015 to May 2017, we collected and analysed questionnaires completed by 397 Thai and 467 non-Thai travellers (total: 50.1% men, median age 37 years). Non-Thai travellers were from Europe (59%), Northern America (21.4%), Asia (16.5%) and Australia or New Zealand (3.0%). Approximately 74% of non-Thais sought pre-travel health information; only 36% of Thais did so. Tourism was the main purpose for travel among both Thais (58.4%) and non-Thais (85.2%). Non-Thais were more likely than Thais to travel as backpackers and perform outdoor activities such as trekking, cycling or swimming. The average length of stay in Myanmar among non-Thais was significantly longer than that of Thais (26.58 days vs 7.08 days, P < 0.001). Health problems were reported by 22.9% of non-Thais; the most common was diarrhoea (21.0%) followed by upper respiratory tract symptoms (9.2%), fever (3.4%) and skin problems (3.0%). Only 12.6% of Thais reported health problems, the most common being upper respiratory tract symptoms (7.6%), followed by diarrhoea (3.1%), fever (2.8%) and skin problems (2.0%). Most health problems were mild and self-limited in both groups. Only one Thai and eight non-Thai travellers required a doctor's visit during their trip to Myanmar, and two non-Thais required hospitalization., Conclusions: Health problems are not very common among travellers to Myanmar. Overall, health problems were reported among 18.2% of travellers in our study. Most problems were mild, with spontaneous recovery. Only two foreign travellers required hospitalization., (© International Society of Travel Medicine, 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com)

Background: Therapeutic options for treating advanced or metastatic medullary thyroid carcinoma (MTC) and anaplastic thyroid carcinoma (ATC) are still limited in Japan, even though vandetanib for MTC and lenvatinib for MTC and ATC have been approved. Sorafenib is an oral multikinase inhibitor approved for the treatment of patients with radioactive iodine-refractory differentiated thyroid cancer (DTC). An uncontrolled, open-label, multicenter, single-arm, Phase 2 clinical study was conducted to evaluate the safety and efficacy of sorafenib in Japanese patients with MTC and ATC., Methods: Japanese patients with histologically confirmed ATC and locally advanced or metastatic MTC were enrolled from April to September 2014. The primary endpoint was to evaluate the safety of sorafenib. Treatment efficacy variables including progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR), and maximum reduction in tumor size were evaluated as secondary endpoints. Patients received sorafenib 400 mg orally twice daily on a continuous basis and then continued treatment until the occurrence of disease progression, unacceptable toxicity, or withdrawal of consent., Results: A total of 20 patients were screened, and 18 (8 with MTC and 10 with ATC) were enrolled. The most common drug-related adverse events were palmar-plantar erythrodysesthesia (72%), alopecia (56%), hypertension (56%), and diarrhea (44%). In the ATC patients, median PFS was 2.8 months [confidence interval 0.7-5.6], and median OS was 5.0 months [confidence interval 0.7-5.7]; ORR and DCR were 0% and 40%, respectively. In the MTC population, neither median PFS nor OS had been reached at the time of this analysis; ORR was 25% and DCR was 75%., Conclusions: The toxicities reported in this study were consistent with the known safety profile of sorafenib. Sorafenib seems to be effective in the treatment of advanced MTC but not ATC, and could be a new treatment option for locally advanced or metastatic MTC and radioactive iodine-refractory DTC.

Background: International travel, particularly to developing countries, is becoming increasingly common among the Israeli population, including an increase in the number of travelling children. Since children are a distinct travellers' population, data about their post-travel morbidity are needed., Methods: A retrospective study which examined all children (0-19 years old) who presented to our centre after international travel from 1999 to 2015., Results: About 314 children were seen. The mean age was 10 years (SD ± 5.8). Most of the patients (80.6%) were tourists, and the rest were expatriates. The main destinations visited were South-Asia (46.5%), Sub-Saharan Africa (33.4%), Latin-America (7%) and Europe (6.4%). Overall, the most common diagnoses were gastrointestinal (GI) (mainly chronic) disorders (30.6%), followed by febrile diseases (26.4%), among which 18.1% of patients were diagnosed with dengue fever and 12% with malaria. Dermatologic conditions accounted for 25.2%. Additional diagnoses were schistosomiasis (6.4%) and neuropsychiatric symptoms (2.2%). A substantial part, 10.8%, had eosinophilia, either symptomatic or asymptomatic. Travellers to Asia, compared to travellers to Africa, presented more commonly with GI illness (OR 2.02, 95% confidence interval 1.13-3.61), and dermatologic conditions (OR 1.94, 95% confidence interval 1.05-3.61). Morbidity was associated with a variety of transmission modes, such as food-borne illnesses (30.9%), bite and sting wounds (10.2%), mosquito-borne infections (8%), freshwater contact (6.7%) and tick-borne infections (2.2%)., Conclusion: The main conditions seen in paediatric returning travellers were GI, febrile and dermatologic illnesses, some may be rare in their country of origin. Targeting care for the suspected pathogens based on updated knowledge of epidemiology and thorough travel history is essential., (© International Society of Travel Medicine, 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com)

Clostridium difficile is one of the main etiological agents causing antibiotic-associated diarrhea. This study investigated the genetic diversity of 70 toxigenic C. difficile isolates from two Korean hospitals by employing toxinotyping, ribotyping, multilocus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE). Toxin gene amplification resulted in 68 A⁺B⁺ and two A-B+ isolates. Most isolates (95.7-100%) were susceptible to daptomycin, metronidazole, and vancomycin. Seventy C. difficile isolates were classified into five toxinotypes, 19 ribotypes, 16 sequence types (STs), and 33 arbitrary pulsotypes. All C. difficile isolates of ribotype 018 (n = 38) were classified into ST17, which was the most prevalent ST in both hospitals. However, C. difficile isolates of ST17 (ribotype 018) exhibited pulsotypes that differed by hospital. ST2 (ribotype 014/020), 8 (ribotypes 002), 17 (ribotype 018), and 35 (ribotypes 015) were detected in both hospitals, whereas other STs were unique to each hospital. Statistical comparison of the different typing methods revealed that ribotyping and PFGE were highly predictive of STs. In conclusion, our epidemiological study indicates that C. difficile infections in both hospitals are associated with the persistence of endemic clones coupled with the emergence of many unique clones. A combination of MLST with PFGE or ribotyping could be useful for monitoring epidemic C. difficile strains and the emergence of new clones in hospitals.

Norovirus and sapovirus are important causes of acute gastroenteritis (AGE) among American Indian infants. We investigated the prevalence and molecular epidemiology of norovirus and sapovirus in American Indian infants who have historically experienced a high burden of AGE compared to other US populations. Stool samples were collected from 241 children with AGE (cases) and from 343 infants without AGE (controls) ≤9 months of age from 2002-2004. Cases experienced forceful vomiting and/or 3 or more watery or looser-than-normal stools in 24 hours. Stools were tested by real-time RT-PCR for norovirus GI, GII and GIV and sapovirus GI, GII, GIV and GV. Positive samples were genotyped after sequencing conventional RT-PCR products. Norovirus was identified in 76 (31.5%) of the cases and 70 (20.4%) of the controls (p<0.001). GII.3 and GII.4 Farmington Hills were the most frequently identified genotypes in 14.5% and 30.3% of cases and 17.1% and 27.1% of controls, respectively. Sapovirus GI and GII genotypes were identified in 8 (3.3%) of cases and 8 (2.3%) of controls and a single GIV virus was detected in a control. The same norovirus and sapovirus genotypes were circulating in the general U.S. population in the same time period. The high detection rate of norovirus in healthy controls suggests significant asymptomatic transmission in young infants in these communities., Competing Interests: The authors have declared that no competing interests exist.

Background: Traveller's diarrhoea (TD) is the most common infectious problem for travellers, and we lack effective ways of preventing it, apart from antibiotic prophylaxis. This study aims to quantify the risk reduction of a hypothetic TD vaccine Norwegian travellers are willing to pay for., Methods: 1204 clients at Reiseklinikken responded to a questionnaire asking what level of effectiveness would be required of a hypothetical vaccine against TD costing US$65., Results: 18.7% of the respondents would buy the vaccine even if it was only 20% effective. Among respondents older than 50 years, the proportion was 28.8%., Conclusions: Our findings should encourage the development of vaccines and other preventive measures against travellers' diarrhoea., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives Diarrheal disease is a significant cause of morbidity among children in Peru. Oral rehydration therapy (ORT) is a cost-effective evidence-based approach to treat diarrhea in young children, yet many Peruvian children in poorer households do not receive this life-saving treatment. This study investigates the social determinants of care-seeking behavior and utilization of appropriate home treatment for diarrheal episodes. Methods We used the nationally-representative 2008 Peru Demographic and Health Survey to: (1) describe the burden of non-bloody diarrheal disease among children <5 years old; and (2) identify socioeconomic correlates of care-seeking behavior and utilization/appropriateness of treatment among mothers of children with recent non-bloody diarrheal episodes (N = 1365). For the former, we reported descriptive statistics; for the latter, we utilized logistic regression to generate odds ratios. Results 2-week period prevalence of diarrheal disease was almost twice as high among poor (17 %) compared with wealthier (10 %) children, higher among children aged 12-23 months old (22 %), and higher among children from households that do not have an improved source of drinking water (16 %) compared with those that have an improved source (12 %). Interestingly, rural residence was a significant predictor of seeking care for diarrhea. Furthermore, although widely available, few mothers (15 %) used appropriate treatment for a recent diarrheal episode. Water source, mother's education, and wealth were significant predictors of appropriate home treatment. Conclusions Mothers in rural areas-typically with less access to care-were more likely to seek care for diarrheal disease in their children, even when adjusting for other variables. However, this increase in care seeking behavior did not extend to appropriate home treatment. Innovative behavior change strategies to reduce barriers to access and appropriate home treatment for diarrheal disease are important, especially given effective and affordable treatment strategies. Future studies should elucidate specific barriers to seeking and utilizing ORT and other appropriate home treatments.

(1) BACKGROUND/OBJECTIVES: The Paleolithic diet has been receiving media coverage in Australia and claims to improve overall health. The diet removes grains and dairy, whilst encouraging consumption of fruits, vegetables, meat, eggs and nuts. Our aim was to compare the diet to the Australian Guide to Healthy Eating (AGHE) in terms of compliance, palatability and feasibility; (2) SUBJECTS/METHODS: 39 healthy women (age 47 ± 13 years, BMI 27 ± 4 kg/m²) were randomised to an ad-libitum Paleolithic (n = 22) or AGHE diet (n = 17) for 4-weeks. A food checklist was completed daily, with mean discretionary consumption (serves/day) calculated to assess compliance. A 12-item questionnaire was administered post intervention to assess palatability and feasibility; (3) RESULTS: The AGHE group reported greater daily consumption of discretionary items (1.0 + 0.6 vs. 0.57 + 0.6 serves/day, p = 0.03). Compared to the AGHE group, the Paleolithic group reported a significantly greater number of events of diarrhoea (23%, 0%, p = 0.046), costs associated with grocery shopping (69%, 6% p < 0.01) and belief that the diet was not healthy (43%, 0% p < 0.01); (4) CONCLUSIONS: Compliance to both diets was high but the potential side effects and increased cost suggest that the Paleolithic diet may not be practical in clinical/public health settings. Further studies are required to assess longer term feasibility.

Background: Despite significant achievements in health indicators during previous decades, Vietnam lags behind other developing countries in reducing common early childhood illnesses, such as diarrhea and respiratory infections. To date, there has been little research into factors that contribute to the prevalence and treatment of childhood morbidity in Vietnam., Objective: This study examines the determinants of diarrhea and 'illness with a cough' and treatments for each of the conditions among young children in Vietnam, and describes trends over time., Design: Data from the Vietnam Multiple Indicator Cluster Surveys in 2000, 2006, and 2011 were used. Multivariable logistic regressions were undertaken to investigate factors associated with these childhood illnesses and proper treatment patterns., Results: Between 2000 and 2011, the prevalence of diarrhea among children under the age of five declined from 11 to 7%, while having illness with a cough increased to 40% in 2011 after falling from 69 to 28% between 2000 and 2006. During the same period, the prevalence of oral rehydration therapy (ORT) for treating diarrhea increased from 13 to 46%, whereas the rate of seeking formal treatment for illnesses with a cough fell from 24 to 7%. Multivariable models indicated that children who were older than 2 years (odds ration [OR]: 0.44, 95% confidence interval [CI]: 0.37-0.53, p<0.001), male (OR: 1.21, 95% CI: 0.64-2.37, p<0.05), living in rural areas (OR: 1.28, 95% CI: 1.00-1.64, p<0.05), or of Kinh ethnicity (OR: 0.70, 95% CI: 0.56-0.87, p<0.01) were more likely to suffer from diarrhea. Ethnic differences and higher household wealth were factors significantly associated with having illness with a cough. In particular, the effect of level of wealth on illness with a cough varied in each wave. Mothers with higher levels of education had higher odds of seeking ORT compared with mothers with the lowest level of education. Seeking formal treatment for children who have illness with a cough was associated with being in a household in the richest wealth quintile (OR: 0.56, 95% CI: 0.34-0.91, p<0.05)., Conclusions: This study demonstrates the importance of identifying different risk factors for these two illnesses and also factors associated with healthcare-seeking behaviors in order to reduce the burden of childhood morbidity in Vietnam. Policies aimed at tackling childhood morbidities should include comprehensive strategies that impact on socioeconomic and environmental factors.

Objective: to report the experience of investigating the outbreak of acute diarrhoea (AD) at the XII Indigenous Games in Cuiabá, Mato Grosso, Brazil, 2013., Methods: data were collected from the Advanced Medical Post's service records of the AD cases, which were defined as 'individual Games participant referring episode of diarrhoea and/or vomiting'; AD attack rates, relative frequencies and measures of the central tendency of sociodemographic and clinical variables, sanitary inspections and results of bromatological samples were calculated., Results: 384 (37%) cases met the definition of AD; the epidemic peaks of the outbreak occurred on the 4th and 7th day of the event and the disease attack rate was 33.5%; sanitary inspection showed evidence of food contamination by coagulase-negative Staphylococci, Bacillus cereus and heat resistant coliforms., Conclusion: there an outbreak of AD caused by food contamination.

Background: Invasive amebiasis is not frequently seen in the United States. It is associated with considerable morbidity in patients residing in or traveling to endemic areas. We report a case series of patients with amebic colitis in a United States-Mexico border city to alert physicians to the varied clinical manifestations., Case Presentation: Nine patients were diagnosed with amebic colitis. Mean age was 56 (38-83), 6 were males, and all were Hispanic. Common symptoms were diarrhea (56 %), hematochezia (33 %) and abdominal bloating (11 %). The diagnosis of amebic colitis was established in the following ways: 8 patients by colonoscopy with biopsy, 1 by surgery for colonic obstruction. The diagnosis of amebic colitis was confirmed in 8 patients (89 %) by amebic trophozoites present in histopathologic sections. One patient was diagnosed with amebic colitis based upon clinical symptoms, colitis on colonoscopy and visualization of amebic trophozoites on stool examination. In the 8 patients in whom colonoscopy was done, 6 (75 %) had inflammation with rectosigmoid involvement and 5 (62.5 %) had ulcerations. Infection resolved after treatment with metronidazole in most patients; however, one patient developed a liver abscess and another had a colonic perforation and later developed a liver abscess., Conclusion: The occurrence of amebic colitis in this United States-Mexico border city hospital population was low, but in some cases potentially life-threatening. Physicians should be alert to the less common presentations of amebic colitis, such as overt gastrointestinal bleeding, exacerbation of inflammatory bowel disease, and the incidental finding of association with colon cancer, or a surgical abdomen. Rectosigmoid involvement was typically found on colonoscopy.

Background: Some rural African communities residing along rivers use the untreated river water for domestic purposes, making them vulnerable to waterborne diseases such as diarrhea., Methods: We determined water use practices and water quality, relating them to prevalence of diarrhea in communities along the Boro-Thamalakane-Boteti river system, northern Botswana. A total of 452 households were interviewed and 196 water samples collected show during February, May, September, and December 2012 in settlements of Boro, Maun, Xobe, Samedupi, Chanoga, and Motopi. Information was sought on water use practices (collection, storage, and handling) and diarrheal experience using questionnaires. Water quality was assessed for physicochemical and microbiological parameters using portable field meters and laboratory analysis, respectively., Results: All (100%) of the river water samples collected were fecally contaminated and unsuitable for domestic use without prior treatment. Samples had Escherichia coli (E.coli) and fecal streptococci levels reaching up to 186 and 140 CFU/100 ml, respectively. Study revealed high dependence on the fecally contaminated river water with low uptake of water treatment techniques. Up to 48% of households indicated that they experience diarrhea, with most cases occurring during the early flooding season (May). Nonetheless, there was no significant relationship between river water quality and households' diarrheal experience across studied settlements (p > 0.05). Failure to treat river water before use was a significant predictor of diarrhea (p = 0.028)., Conclusions: Even though the river water was unsafe for domestic use, results imply further recontamination of water at household level highlighting the need for simple and affordable household water treatment techniques.

Background: This study investigates the association between intimate partner violence (IPV) against women and its impact on child morbidity in the south Asian region., Methods: The analysis uses logistic regression models with cross sectional nationally representative data from three countries - Bangladesh, India and Nepal. The data have been pooled from 'Demographic and Health Surveys' (DHS) of Bangladesh, Nepal and 'National Family and Health Survey' (NFHS) of India., Results: The study revealed that after controlling for potential confounders, children of mothers experiencing physical violence, sexual violence or both were more likely to have Acute Respiratory Infection (ARI) (OR(adj) 1.57; 95% CI 1.48-1.67), fever (OR(adj) 1.44; 95% CI 1.35-1.54) and diarrhea (OR(adj )1.56; 95% CI 1.44-1.69)., Conclusions: The results highlight that IPV can influence childhood morbidity and support the need to address IPV with a greater focus within current child nutrition and health programs and policies.

Background: Zulu people living in the rural area of Maputaland (KwaZulu-Natal, South Africa) rely heavily on medicinal plants for the treatment of diarrhoea. Abundant availability of medicinal plants in the study area offers low cost health care, but scientific validation is needed in order to lend credibility to the traditional use against many ailments including diarrhoeal infections. With this in mind a study was designed to test the in vitro antimicrobial efficacy of 23 plant species which are used for the treatment of diarrhoea in rural Maputaland. Four 1:1 plant combinations were also evaluated to determine their interactive effects against seven diarrhoea-related bacterial pathogens., Methods: Minimum inhibitory concentration (MIC) assays were undertaken on dichloromethane-methanol (CH2Cl2: MeOH) and aqueous crude extracts. The following micro-organisms were selected for this study and were tested based on their association with stomach ailments and diarrhoea; Bacillus cereus (ATCC 11778), Enterococcus faecalis (ATCC 29212), Escherichia coli (ATCC 8739), Proteus vulgaris (ATCC 33420), Salmonella typhimurium (ATCC 14028), Shigella flexneri (ATCC 25875) and Staphylococcus aureus (ATCC 12600). The fractional inhibitory concentration index (ΣFIC) was determined for plants traditionally used in combination., Results: Shigella flexneri proved to be the most susceptible pathogen, where the organic extract of Terminalia sericea showed the most prominent noteworthy antibacterial activity (mean MIC value of 0.04 mg/mL). The aqueous extracts generally showed poorer antimicrobial activity with some exceptions i.e. Acacia burkei, Brachylaena transvaalensis against B. cereus and B. transvaalensis against S. flexneri. In the combination studies, synergy was predominant with mean (across all pathogens) ΣFIC values of 0.30 for Acanthospermum glabratum with Krauseola mosambicina; ΣFIC values of 0.46 for A. glabratum with Psidium guajava; ΣFIC values of 0.39 for B. transvaalensis with P. guajava and ΣFIC values of 0.88 (additive) for the combination of B. transvaalensis with Sclerocarya birrea., Conclusion: This study provided some insight into the bacterial in vitro efficacies of plants traditionally used to treat diarrhoea by the people of Northern Maputaland. Very little connection was observed between frequency of use and efficacy. Plant combinations demonstrated favourable efficacy with mostly synergistic effects noted, lending some credibility to their use in combination.

Objective: Antibiotic-associated diarrhea (AAD) and Clostridium difficile infection (CDI) are well-known outcomes from antibiotic administration. Because emergency department (ED) visits frequently result in antibiotic use, we evaluated the frequency of AAD/CDI in adults treated and discharged home with new prescriptions for antibiotics to identify risk factors for acquiring AAD/CDI., Methods: This prospective multicenter cohort study enrolled adult patients who received antibiotics in the ED and were discharged with a new prescription for antibiotics. Antibiotic-associated diarrhea was defined as 3 or more loose stools for 2 days or more within 30 days of starting the antibiotic. C difficile infection was defined by the detection of toxin A or B within this same period. We used multivariate logistic regression to assess predictors of developing AAD., Results: We enrolled and followed 247 patients; 45 (18%) developed AAD, and 2 (1%) developed CDI. Patients who received intravenous (IV) antibiotics in the ED were more likely to develop AAD/CDI than patients who did not: 25.7% (95% confidence interval [CI], 17.4-34.0) vs 12.3% (95% CI, 6.8-17.9). Intravenous antibiotics had adjusted odds ratio of 2.73 (95% CI, 1.38-5.43), and Hispanic ethnicity had adjusted odds ratio of 3.04 (95% CI, 1.40-6.58). Both patients with CDI had received IV doses of broad-spectrum antibiotics., Conclusion: Intravenous antibiotic therapy administered to ED patients before discharge was associated with higher rates of AAD and with 2 cases of CDI. Care should be taken when deciding to use broad-spectrum IV antibiotics to treat ED patients before discharge home., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: During the US Civil War, medical officers typically attributed night blindness among soldiers to malingering. A dietary basis was not generally suspected or appreciated., Design/methods: Incident cases of night blindness, scurvy, and diarrheal diseases, as well as mean troop strength among Union troops, were abstracted by month and race from tabulations of the US Surgeon General for the period from July 1861 through June 1866. Monthly incidence rates and annual incidence rates are presented as time series by race., Results: Night blindness incidence was seasonal. Seasonal patterns of night blindness incidence were similar for white and black soldiers, although the peak incidence rates were approximately 2-3 times higher in black soldiers. The seasonal effect for white Union soldiers increased progressively to 1864. The seasonal pattern for night blindness roughly parallels that for scurvy and for diarrheal diseases. The peak season for night blindness incidence was summer, and the next highest season was spring. The mode of monthly incidence rates for diarrheal diseases slightly anticipated that for night blindness and scurvy. In addition, there was greater relative variation in monthly incidence for night blindness and scurvy than for diarrheal diseases., Conclusions: Nutritional night blindness occurred in a seasonal pattern among soldiers forced to subsist on nutritionally inadequate diets. The seasonal pattern is consistent with seasonal variations in the availability of foodstuffs with high vitamin A or provitamin A content, superimposed on marginal vitamin A reserves, and possibly exacerbated by co-occurring seasonal patterns of diarrheal disease., (© 2014 American Academy of Neurology.)

Background: A patch vaccine containing heat-labile toxin (LT) from enterotoxigenic Escherichia coli (ETEC) has demonstrated to be beneficial in reducing the rate and severity of travelers' diarrhea in Latin America. To evaluate the efficacy of this transdermal vaccine system in an area with a different diarrheal pathogen profile, an additional phase 2 study was conducted in European travelers to India., Methods: For this multicenter, randomized, double-blinded, placebo-controlled field study 723 subjects were recruited; 603 (299 LT vaccine, 304 placebo) were included in the per-protocol-population (PPP)., Results: Although the LT patch induced a measurable LT immune response in recipients, it failed to protect against LT ETEC or all-cause diarrhea. In the PPP the incidence rate of diarrhea as per primary endpoint was 6.0% (18 of 299) in the vaccine group and 5.9% (18 of 304) in the placebo group. Additionally, lower than expected rates of LT ETEC diarrheas were observed in India. The vaccine delivery system frequently produced rash and pruritus at the site of application, long term hyperpigmentation persisted in a minority of LT recipients, and also few site reactions were noted in the placebo group., Conclusions: The evaluated patch vaccine failed to satisfy mainly with respect to protective efficacy. Noninvasive prophylactic agents against travelers' diarrhea, particularly vaccines against the most frequent pathogens, thus continue to be badly needed., (© 2013 International Society of Travel Medicine.)

Each year, more than two million people die from diarrhea-associated diseases. Although there is a global need for safe drinking water, culturally appropriate health teaching is essential to behavior change. This study evaluated the impact of a health education program in a small rural community in Cameroon. Flash cards and a modified version of the CDC-KPC 2000 survey were used to collect data in 57 homes. Children who lived in households with working Manz BioSand filters were less likely to have had diarrhea in the 2 weeks prior to the evaluation. There remained a gap between health knowledge and healthy behaviors for hand hygiene and malaria prevention. This gap was significant in the diarrheal treatment (McNemar's test, p < .000). The interdisciplinary program and 7-year time frame were crucial to sustainability. Faculty and students learned the importance of pairing service learning and research that respect local cultures in fostering a healthier global community.

Background: The vast majority (>75%) of Aboriginal people in the Northern Territory (NT) live in remote or very remote locations. Children in these communities have high attendance rates at local Primary Health Care (PHC) centres but there is a paucity of studies documenting the reason and frequency of attendance. Such data can be used to help guide public health policy and practice., Methods and Findings: Clinic presentations during the first year of life were reviewed for 320 children born from 1 January 2001-31 December 2006. Data collected included reason for infectious presentation, antibiotic prescription and referral to hospital. The median number of presentations per child in the first year of life was 21 (IQR 15-29) with multiple reasons for presentation. The most prominent infectious presentations per child during the first year of life were upper respiratory tract infections (median 6, IQR 3-10); diarrhoea (median 3, IQR 1-5); ear disease (median 3, IQR 1-5); lower respiratory tract infection (median 3, IQR 2-5); scabies (median 3, IQR 1-5); and skin sores (median 3, IQR 2-5)., Conclusions: Infectious diseases of childhood are strongly linked with poverty, poor living conditions and overcrowding. The data reported in our study were collected through manual review, however many remote communities now have established electronic health record systems, use the Key Performance Indicator System and are engaged in CQI (continuous quality improvement) processes. Building on these recent initiatives, there is an opportunity to incorporate routine monitoring of a range of infectious conditions (we suggest diarrhoea, LRTI, scabies and skin sores) using both the age at first presentation and the median number of presentations per child during the first year of life as potential indicators of progress in addressing health inequities in remote communities.

Norovirus (NoV), sapovirus (SaV) and human astrovirus (HAstV) are viral pathogens that are associated with outbreaks and sporadic cases of gastroenteritis. However, little is known about the occurrence of these pathogens in relatively isolated communities, such as the remnants of African-descendant villages ("Quilombola"). The objective of this study was the frequency determination of these viruses in children under 10 years, with and without gastroenteritis, from a "Quilombola" Community, Northern Brazil. A total of 159 stool samples were obtained from April/2008 to July/2010 and tested by an enzyme immunoassay (EIA) and reverse transcription-polymerase chain reaction (RT-PCR) to detect NoV, SaV and HAstV, and further molecular characterization was performed. These viruses were detected only in the diarrheic group. NoV was the most frequent viral agent detected (19.7%-16/81), followed by SaV (2.5%-2/81) and HAstV (1.2%-1/81). Of the 16 NoV-positive samples, 14 were sequenced with primers targeting the B region of the polymerase (ORF1) and the D region of the capsid (ORF2). The results showed a broad genetic diversity of NoV, with 12 strains being classified as GII-4 (5-41.7%), GII-6 (3-25%), GII-7 (2-16.7%), GII-17 (1-8.3%) and GI-2 (1-8.3%), as based on the polymerase region; 12 samples were classified, based on the capsid region, as GII-4 (6-50%, being 3-2006b variant and 3-2010 variant), GII-6 (3-25%), GII-17 (2-16.7%) and GII-20 (1-8.3%). One NoV-strain showed dual genotype specificity, based on the polymerase and capsid region (GII-7/GII-20). This study provides, for the first time, epidemiological and molecular information on the circulation of NoV, SaV and HAstV in African-descendant communities in Northern Brazil and identifies NoV genotypes that were different from those detected previously in studies conducted in the urban area of Belém. It remains to be determined why a broader NoV diversity was observed in such a semi-isolated community.

Aim: To survey irritable bowel syndrome (IBS) using Rome III criteria among Malays from the north-eastern region of Peninsular Malaysia., Methods: A previously validated Malay language Rome III IBS diagnostic questionnaire was used in the current study. A prospective sample of 232 Malay subjects (80% power) was initially screened. Using a stratified random sampling strategy, a total of 221 Malay subjects (112 subjects in a "full time job" and 109 subjects in "no full time job") were recruited. Subjects were visitors (friends and relatives) within the hospital compound and were representative of the local community. Red flags and psychosocial alarm symptoms were also assessed in the current study using previously translated and validated questionnaires. Subjects with IBS were sub-typed into constipation-predominant, diarrhea-predominant, mixed type and un-subtyped. Univariable and multivariable analyses were used to test for association between socioeconomic factors and presence of red flags and psychosocial alarm features among the Malays with IBS., Results: IBS was present in 10.9% (24/221), red flags in 22.2% (49/221) and psychosocial alarm features in 9.0% (20/221). Red flags were more commonly reported in subjects with IBS (83.3%) than psychosocial alarm features (20.8%, P < 0.001). Subjects with IBS were older (mean age 41.4 years vs 36.9 years, P = 0.08), but no difference in gender was noted (P = 0.4). Using univariable analysis, IBS was significantly associated with a tertiary education, high individual income above RM1000, married status, ex-smoker and the presence of red flags (all P < 0.05). In multiple logistic regression analysis, only the presence of red flags was significantly associated with IBS (odds ratio: 0.02, 95%CI: 0.004-0.1, P < 0.001). The commonest IBS sub-type was mixed type (58.3%), followed by constipation-predominant (20.8%), diarrhea-predominant (16.7%) and un-subtyped (4.2%). Four of 13 Malay females (30.8%) with IBS also had menstrual pain. Most subjects with IBS had at least one red flag (70.8%), 12.5% had two red flags and 16.7% with no red flags. The commonest red flag was a bowel habit change in subjects > 50 years old and this was reported by 16.7% of subjects with IBS., Conclusion: Using the Rome III criteria, IBS was common among ethnic Malays from the north-eastern region of Peninsular Malaysia.

Background: Prolonged infectious diarrhoea in the returning traveller is generally caused by protozoal and occasionally by helminth parasites., Objective: This article provides a framework for the diagnosis, management and prevention of the diseases that cause persistent diarrhoea in the traveller., Discussion: A large proportion of disease is caused by Giardia lamblia, Cryptosporidium parvum and Entamoeba histolytica. However, given the ease of travel with comorbid conditions such as human immunodeficiency virus, there is an expanding list of organisms that can cause persistent diarrhoea. An awareness of the likely aetiological agents and their clinical features enables a more effective diagnosis and management of the patient's condition using an appropriate antiparasitic agent. Prevention strategies need to be initiated before travel and should consist of simple but memorable advice. Noninfectious causes of diarrhoea should be considered as diarrhoea can be a prominent feature of conditions such as hyperthyroidism or coeliac disease.

Objective: Beginning in 2006, the Indian Health Service (IHS) began rotavirus vaccination of American Indian and Alaska Native (AI/AN) infants. To assess vaccine impact, we examined trends in IHS diarrhea-associated hospitalization and outpatient visits among AI/AN children in the pre- and postrotavirus vaccine era., Methods: Diarrhea-associated hospitalizations and outpatient visits among AI/AN children <5 years of age during 2001 through 2010 were examined by gender, age group, and region for prevaccine years 2001-2006 and postvaccine years 2008, 2009, and 2010. To account for secular declining trends observed in prevaccine years, expected diarrhea-associated hospitalization and outpatient rates for postvaccine years were generated by using Poisson regression analysis of the 2001-2006 annual rates., Results: Coverage with at least 1 dose of rotavirus vaccine among AI/AN infants aged 3 to 5 months in the first half of 2008, 2009, and 2010 ranged from 48% to 80% in various IHS regions. The prevaccine average annual diarrhea-associated hospitalization rates among AI/AN children <5 years of age was 63 per 10 000 persons (range: 57-75 per 10 000), and declined to 39, 31, and 27 per 10 000 in 2008, 2009, and 2010, respectively. Observed 2008, 2009, and 2010 rates were 24%, 37%, and 44% lower than expected rates, respectively. Decreases in diarrhea-associated hospitalizations and outpatient visits were observed in all IHS regions., Conclusions: Diarrhea-associated hospitalization and outpatient visit rates among AI/AN children have declined after implementation of rotavirus vaccination in AI/AN populations.

Objectives: Deaths due to diarrhea among US children declined substantially from the 1960s through the 1980s, but have not been recently assessed. We examined diarrhea-associated mortality among young US children from 1992 to 2006 to establish baseline estimates through which the effect of rotavirus vaccines, introduced in 2006, can be assessed., Methods: National Center for Health Statistics multiple cause-of-death mortality data were used to examine diarrhea-associated deaths and death rates among US children 1 to 59 months of age during 1992-2006. The winter residual method was used to indirectly estimate the annual number of diarrhea-associated deaths attributable to rotavirus., Results: An average of 369 diarrhea-associated deaths/year (3320 total deaths) occurred among US children 1 to 59 months of age during 1992-1998 and 2005-2006. The diarrhea-associated death rate increased 40% between the first 3 and last 2 years of the study period, from an average of 1.6 deaths per 100,000 to 2.3 deaths per 100,000. Black children died at almost 4 times the rate of white children. Diarrhea-associated deaths showed a winter seasonal pattern similar to that of rotavirus, particularly among children 4 to 23 months of age. Using indirect methods, we estimated 25 yearly rotavirus-associated deaths during the study period. Rotavirus vaccination could potentially prevent 21 of these deaths annually., Conclusions: Diarrhea-associated mortality among US children stabilized but appears to be increasing in recent years. Rotavirus was associated with a small but significant number of preventable deaths. The national multiple cause-of-death data should prove useful for assessing mortality impact of rotavirus vaccination in the United States.

Background: In Vietnam, primary government health services are now accessible for the whole population including ethnic minority groups (EMGs) living in rural and mountainous areas. However, little is known about EMGs' own perspectives on illness treatment and use of health services. This study investigates treatment seeking strategies for child diarrhoea among ethnic minority caregivers in Northern Vietnam in order to suggest improvements to health services for EMGs and other vulnerable groups., Methods: The study obtained qualitative data from eight months of field work among four EMGs in lowland and highland villages in the Northern Lao Cai province. Triangulation of methods included in-depth interviews with 43 caregivers of pre-school children (six years and below) who had a case of diarrhoea during the past month, three focus group discussions (FGDs) with men, and two weeks of observations at two Communal Health Stations (CHGs). Data was content-analyzed by ordering data into empirically and theoretically inspired themes and sub-categories assisted by the software NVivo8., Results: This study identified several obstacles for EMG caregivers seeking health services, including: gender roles, long travelling distances for highland villagers, concerns about the indirect costs of treatment and a reluctance to use government health facilities due to feelings of being treated disrespectfully by health staff. However, ethnic minority caregivers all recognized the danger signs of child diarrhoea and actively sought simultaneous treatment in different health care systems and home-based care. Treatments were selected by matching the perceived cause and severity of the disease with the 'compatibility' of different treatments to the child., Conclusions: In order to improve EMGs' use of government health services it is necessary to improve the communication skills of health staff and to acknowledge both EMGs' explanatory disease models and the significant socio-economic constraints they experience. Broader health promotion programs should address the significant gender roles preventing highland mothers from seeking health services and include family elders and fathers in future health promotion programs. Encouraging existing child health care practices, including continued breastfeeding during illness and the use of home-made rehydration solutions, also present important opportunities for future child health promotion.

Background: Rifaximin has been shown to be effective in treating and preventing travelers' diarrhea (TD) during the summer season., Methods: The goal of this double-blinded multicenter trial was to assess the efficacy and safety of rifaximin 550 mg administered once daily for 14 days compared with placebo in the prevention of TD during the dry season in Mexico., Results: There were 101 participants randomized. Overall, 25 participants developed TD during the 3 weeks of the study: 22% from the rifaximin group and 29% from the placebo group (p = 0.4). Mild diarrhea (defined as only one or two unformed stools during a 24-h period plus at least one abdominal symptoms) developed in only 3 (6%) participants taking rifaximin compared with 10 (21%) taking placebo during the first week of study (p = 0.03). No clinically significant or serious adverse events were reported., Conclusions: Antibiotic prophylaxis of TD in Mexico during the dry season needs to be further studied and its benefits weighed against the benefits of self-treatment., (© 2011 International Society of Travel Medicine.)

Background: Diarrhea is a major cause of death in children in developing countries. However, in Brazil, diarrhea-related morbidity and mortality have declined over the past decades., Objective: To explore community perspectives in Brazil on changes in health related to diarrhea and factors that may have contributed to these changes., Methods: This qualitative study included 12 focus group sessions held with 50 mothers and 42 grandmothers in the state of Ceará., Results: Most grandmothers reported having lost at least one child to diarrhea, and all participants had witnessed children dying from diarrhea in the past. The participants saw a clear decline in diarrhea over the past 20 years. They felt that this was due to social, economic, and cultural progress. The participants also considered government-supported outreach programs very important for health improvement., Conclusions: Knowledge of diarrhea and its causes in the community is broad, but many traditional beliefs about the illness still prevail. The Brazilian experience is an example of the critical effect that policies to promote income redistribution and universal access to education, health, water supply, and sanitation services may have on the reduction of undernutrition and diarrhea among children.

Objective: The effectiveness of probiotic therapy for acute rotavirus infectious diarrhoea in an indigenous setting with bacterial/parasitic diarrhoea is unclear. In the present study, we assessed the efficacy of probiotics in Australian Aboriginal children in the Northern Territory admitted to hospital with diarrhoeal disease., Patients and Methods: A randomised double-blind placebo-controlled study was conducted in Aboriginal children (ages 4 months-2 years), admitted to hospital with acute diarrhoeal disease (>3 loose stools per day). Children received either oral Lactobacillus GG (5 x 10(9) colony-forming units 3 times per day for 3 days; n = 33) or placebo (n = 31). Small intestinal functional capacity was assessed by the noninvasive 13C-sucrose breath test on days 1 and 4., Results: Both groups showed mean improvement in the sucrose breath test after 4 days; however, there was no difference (mean, 95% confidence interval) between probiotic (2.9 [cumulative percentage of dose recovered at 90 minutes]; 1.7-4.2) and placebo (3.7; 2.3-5.2) groups. Probiotics did not change the duration of diarrhoea, total diarrhoea stools, or diarrhoea score compared with placebo. There was a significant (P < 0.05) difference in diarrhoea frequency on day 2 between probiotics (3.3 [loose stools]; 2.5-4.3) and placebo (4.7; 3.8-5.7) groups., Conclusions: Lactobacillus GG did not appear to enhance short-term recovery following acute diarrhoeal illness in this setting.

Background: There is limited epidemiological research that provides insight into the complex web of causative and moderating factors that links housing conditions to a variety of poor health outcomes. This study explores the relationship between housing conditions (with a primary focus on the functional state of infrastructure) and common childhood illness in remote Australian Aboriginal communities for the purpose of informing development of housing interventions to improve child health., Methods: Hierarchical multi-level analysis of association between carer report of common childhood illnesses and functional and hygienic state of housing infrastructure, socio-economic, psychosocial and health related behaviours using baseline survey data from a housing intervention study., Results: Multivariate analysis showed a strong independent association between report of respiratory infection and overall functional condition of the house (Odds Ratio (OR) 3.00; 95%CI 1.36-6.63), but no significant association between report of other illnesses and the overall functional condition or the functional condition of infrastructure required for specific healthy living practices. Associations between report of child illness and secondary explanatory variables which showed an OR of 2 or more included: for skin infection--evidence of poor temperature control in the house (OR 3.25; 95%CI 1.06-9.94), evidence of pests and vermin in the house (OR 2.88; 95%CI 1.25-6.60); for respiratory infection--breastfeeding in infancy (OR 0.27; 95%CI 0.14-0.49); for diarrhoea/vomiting--hygienic state of food preparation and storage areas (OR 2.10; 95%CI 1.10-4.00); for ear infection--child care attendance (OR 2.25; 95%CI 1.26-3.99)., Conclusion: These findings add to other evidence that building programs need to be supported by a range of other social and behavioural interventions for potential health gains to be more fully realised.

Objective: Devise and implement evidence-based guidelines for the prevention and management of travellers' diarrhoea (TD), and establish the incidence of TD during an elite sporting trip to India., Design: Literature review and audit., Setting: Youth Commonwealth Games in India 2008., Participants: All members of the Team England Squad., Main Outcome Measures: Hygiene guidelines included only drinking bottled water, eating hot food and regular hand washing with alcohol gel. Ciprofloxacin was offered to non-athlete team members as prophylaxis but not to athletes due to its possible association with tendon disease. Following implementation of these guidelines, the incidence of travellers' diarrhoea (TD) in the whole squad was 24/122 (20%), compared with 7/14 (50%) on the reconnaissance trip (preguidelines). In those taking prophylactic ciprofloxacin, the incidence was 4/33 (12%), compared with 20/89 (23%) in those not taking ciprofloxacin. No athlete missed their event due to TD., Conclusions: The incidence of TD was less during the event than on the reconnaissance trip. The relative contribution to this reduction in strict hygiene guidelines as compared with potentially improved catering hygiene arrangements is unknown. Prophylactic ciprofloxacin also reduced the incidence of TD but it is probably not appropriate for use in elite athletes. Rifaximin may be an alternative for this group.

In this research project, we studied factors that presumably affect the incidence of diarrhoea among young children in urban slums in developing countries: consumption of safe drinks, hygiene behaviour, cleanliness of household surroundings and the quality of raw water. Beliefs concerning the causes of diarrhoea were also related to health-improving behaviour, namely the application of the water-treatment method SODIS (solar water disinfection) and hygiene behaviour. We conducted a survey in a shanty town in Nairobi, Kenya. Field workers interviewed 500 households. Analysis with regression models revealed that two out of the four postulated factors were significant: children have a lower risk of contracting diarrhoea when they consume high percentages of safe drinks and live in households with good hygiene. As regards beliefs, we found that biomedical knowledge of children's diarrhoea as well as the perceived social norm for treating water was associated with the use of SODIS and good hygiene.

Objectives: This report is a preliminary comparative study of irritable bowel syndrome symptoms in eight countries, USA, Mexico, Canada, England, Italy, Israel, India, and China. We also assessed global symptom patterns and correlations and relationships to several psychosocial variables., Methods: Two hundred and thirty-nine participants completed a bowel symptom scale composed of four symptoms, abdominal pain or discomfort, bloating, diarrhea, and constipation as well as two psychosocial questionnaires, quality of relationship and attribution of symptoms to physical or emotional factors., Results: Pain score in Italy, with the least urban population, was significantly higher than six of the seven other countries whereas it was lowest in India and England. Bloating was highest in Italy and constipation was highest in Mexico, both significantly higher than five other countries. Diarrhea was higher in China than five other countries. All significance values were P<0.05. Globally, diarrhea was less common than constipation, P<0.001 and bloating significantly correlated with constipation as well with pain, P<0.05. Composite analysis of psychosocial variables and symptoms indicated that family conflict correlated directly, P<0.05, whereas family support correlated indirectly, P<0.01, with pain and bloating. Pain, bloating and diarrhea were significantly attributed to physical etiology, P<0.01, whereas only diarrhea was attributed to emotional cause, P<0.05., Conclusion: This study suggests that there are significant variations in irritable bowel syndrome symptoms in different geographic locations around the world. Various hypotheses that may explain our data such as cultural beliefs, gut contamination, urban and rural location, dietary practice, and psychosocial factors should be further investigated.

This paper takes the theoretical construct of popular nosology of Latino folk illnesses and combines it with Edward Casey's concept of bodily remembering in order to more fully describe the role of memory and place in the illness experiences of the Amuzgos Indians of Oaxaca, Mexico. I ethnographically describe, across time, the interrelated links among social events, physical symptoms, and illness narratives of Latino folk illness popular nosologies as they are contextualized in their unique, social topographies. This enlarged theoretical perspective implies a smallest unit of meaning that is ethnographically defined, but that will often encompass more than the individual sufferer and more than one illness. The research objective of this study was to understand Amuzgan illness experiences through the narratives of detailed case histories and ethnographic observations that were gathered during 18 months of qualitative research. The data show that Amuzgos experience Latino folk illnesses as bodily rememberings of illness events combined with negative interpersonal interactions. Healing these Latino folk illnesses implies curing bodies, households, social relationships, and living environments.

Background: Diarrhea accounts for many hospitalizations and outpatient clinic visits among children. American Indian and Alaska Native (AI/AN) children have experienced a greater infectious disease burden compared with the general U.S. population of children, although diarrhea-associated hospitalization rates have declined among AI/AN children., Methods: Hospital discharge and outpatient visit records with a diagnosis indicating a diarrhea-associated diagnosis were evaluated for AI/AN children <5 years of age, using the 2000-2004 Indian Health Service Direct and Contract Health Service Inpatient Data and outpatient visit data from the Indian Health Service National Patient Information Reporting System, and for the general U.S. population of children <5 years of age using the Kids' Inpatient Database for 2003 and National Ambulatory data for 2000-2004., Results: For 2000-2004, the diarrhea-associated hospitalization rate was similar for AI/AN children and U.S. children <5 years of age (65.9 and 79.3 of 10,000, respectively), but the rate among AI/AN infants was nearly twice the rate among U.S. infants (262.6 and 154.7 of 10,000, respectively). The rate of diarrhea-associated outpatient visits among AI/AN children was higher than for U.S. children (2255.4 versus 1647.9 of 10,000, respectively), as a result of the high rate among AI/AN infants compared with U.S. infants (6103.5 and 2956.3 of 10,000, respectively)., Conclusions: Although the diarrhea-associated hospitalization rate in AI/AN children <5 years old has declined to levels comparable with that of all U.S. children, the rate for AI/AN in infants remains higher than for U.S. infants. The diarrhea-associated outpatient visit rate for AI/AN children was higher than for U.S. children. Ongoing evaluation of hospitalization and outpatient data is important to understand the impact of rotavirus vaccine among AI/AN children.

Background: Clostridium difficile-associated diarrhea (CDAD) has been increasingly diagnosed in hospitalized patients. The number of prescriptions for proton pump inhibitors (PPIs) has also increased significantly over time. Few studies have reported an association between CDAD and PPI use; however, the results are inconclusive., Objective: To determine the relationship between CDAD and PPI use in African-American and Hispanic patients., Methods: We retrospectively reviewed medical records of 640 cases with CDAD over nine years, diagnosed by the presence of C. difficile toxin in the stools. Age-/ sex-matched 650 patients with diarrhea but absent C. difficile toxin in stools were used as controls., Results: Of the 640 cases, 576 (90%) received antibiotics and 32 (5%) received chemotherapy during the preceding three months. Of the 650 controls, 540 (83%) received antibiotics and 39 (6%) received chemotherapy during the preceding three months. CDAD was associated with the use of antibiotics or chemotherapy (OR = 2.3, 95% CI: 1.5-3.7). Of the 608 cases receiving antibiotics or chemotherapy, 274 (45%) also received PPI within the preceding three months. Of the 579 controls who received antibiotics or chemotherapy, 169 (29%) also received PPI within preceding three months. CDAD was associated with the use of PPI (OR = 2.0, 95% CI: 1.6-2.6)., Conclusion: Our findings indicate that PPI may be an emerging and potentially modifiable risk factor for CDAD and point out the importance of vigilance in prescribing PPI, particularly to patients who are hospitalized, taking multiple antibiotics and suffering from multiple comorbidities.

Background: The Middle East is one of the most rapidly growing destination for travelers. Objective. The aim of this study was to determine the medical conditions affecting travelers needing medical assistance in Bahrain International Airport (BIA)., Method: Logbook documenting medical conditions of travelers presenting to the BIA clinic from January 1 till the end of December 2004 was reviewed., Results: A total of 3,350 travelers attended the clinic, constituting 0.12% of the disembarking and transit travelers. Most common conditions faced were respiratory problems (24.4%), followed by headaches (19.2%), trauma, musculoskeletal pains (12.9%), and gastrointestinal problems (11.0%). Only 2.1% of all complaints were referred to secondary care. The majority of cases were handled by the nurse., Conclusions: Majority of the patients examined had acute minor medical problems. Ninety-eight percent of conditions affecting travelers were handled in the airport clinic by the nurse and the family physician. Airport clinic could serve as an efficient emergency triage system for filtering serious illnesses needing urgent management.

Diarrhoeal disease is a major public health problem in Thailand. We collected information on childhood diarrhoea from a district in northeast Thailand, using various approaches which focus on both consumers and providers. The overall incidence of diarrhoea in the study area was 2.1 episodes per child per 12 months, with children under two years of age having a higher rate at 3.0 episodes per child per 12 months. Many episodes were not recognized as diarrhoeal episodes by caregivers, and treatment was sought in just over half of all episodes. Although children received an average of 2.4 items of medicine per episode, there was relatively low use of oral rehydration solutions. This study highlights the importance of assessing local beliefs when collecting data on diarrhoeal diseases in children, and the importance of continuing efforts to improve public health education on the management of diarrhoeal diseases.

In Denmark, about one third of notifiable diseases are imported, but these have had only a limited spread within the Danish community. For example, imported strains of Mycobacterium tuberculosis remain confined to the immigrant population, and the high prevalence of chronic hepatitis B among certain groups of immigrants has not resulted in a general increase in the incidence of hepatitis B. Exceptions are imported cases of hepatitis A in children, which have resulted in outbreaks in the indigenous Danish population, and the import of drug-resistant bacteria, which often pose a serious challenge to hospital hygiene.

As a part of an interdisciplinary research and action programme, morbidity and nutritional patterns were assessed in three nomadic communities: Fulani and Arab cattle breeders and Arab camel breeders, of two prefectures in Chad. The predominant morbidity pattern of Chadian nomadic pastoralists (representing approximately 10% of the total population of the country) had not been documented so far. A total of 1092 women, men and children was examined by a physician and interviewed during two surveys in the dry season and one in the wet season (1999--2000). Participants with no complaint were rare. Pulmonary disorders (e.g. bronchitis) were most often diagnosed for children under 5 years of age. Of the adult participants, 4.6% were suspected of tuberculosis. Febrile diarrhoea occurred more often during the wet season when access to clean drinking water was precarious. Malaria was only rarely clinically diagnosed among Arabs during the dry season, whereas Fulani, who stayed in the vicinity of Lake Chad, were also affected during this period. A 24-h dietary recall showed that less Arab women than men consumed milk during the dry season (66% versus 92%). Malnutrition was only documented for 3 out of 328 children (0--14 years). Arab women in childbearing age had a higher proportion of children not surviving when compared to Fulani women (0.2 versus 0.07). This study identified several implications for reseach and interventions in nomadic settings. Innovative and integrated health services for nomads can possibly be extended to many settings as nomadic pastoralists have in common a similar way of life driven by the needs of their animals.

Background: Irritable bowel syndrome has been said to be less common in developing countries compared with western populations. In some case series of irritable bowel syndrome from the Indian subcontinent and Africa, the female predominance typical of western patients did not occur., Aim and Methods: A systematic review was performed on Medline, of community prevalence studies of irritable bowel syndrome, chronic constipation and chronic diarrhoea using standardized criteria, with special reference to the effect of geography and ethnicity, and the gender distribution in different countries., Results: There is a wide variation, depending in part on the criteria used and differences in diagnostic practices and health care utilization. No convincing evidence emerged of a difference between east and west. Most series, eastern or western showed a female predominance or no gender difference. Several US studies in communities and specific populations suggest that stool frequency is lower, and the prevalence of constipation higher, among Afro-Caribbean Americans compared with white individuals., Conclusions: Community studies in multi-racial populations are a useful way of assessing possible ethnic differences in the frequency of irritable bowel syndrome, chronic constipation and diarrhoea, and would additionally present opportunities to relate any ethnic differences to dietary and other environmental factors.

A multilevel proportional hazards model was used to determine the prognostic factors affecting hospitalisations for recurrent diarrhoeal disease in infants and young children. All infants born in 1996 who had index gastroenteritis admission to Western Australian (WA) hospitals during their first year of life were included in our study cohort (n = 486). There were 618 hospital admissions for infectious diarrhoea over the 6-year follow-up period. Aboriginal children stayed significantly longer in hospital than their non-Aboriginal peers, and comorbidities such as dehydration, gastrointestinal sugar intolerance, failure to thrive, iron deficiency anaemia and certain infections (genitourinary, scabies and/or otitis media) were all significantly associated with the delayed discharge of patients. Substantial variations among patients (variance = 0.660) and between health service regions of WA (variance = 0.296) were found. Over 30% of the total variation could be attributed to the heterogeneity between health districts. For any two patients in the same health district, the within-region (intraclass) correlation was estimated to be 0.309. In the absence of detailed socio-demographic data, application of the standard survival procedure may lead to incorrect inferences due to regional clustering and repeated observations on individuals. By accounting for latent patient and regional effects, the multilevel analysis clearly confirmed the high burden of infectious diarrhoea among Aboriginal infants and children, and their much longer hospital stays. Coexisting morbidities contributed to the prolonged and recurrent hospitalisations. Findings of this epidemiological study indicated the need of multifaceted clinical disease prevention and hygiene promotion strategies to control the disease.

Decades of apartheid policies have resulted in marked racial inequalities in health in South Africa. The black:white rate ratio of diarrhoea among children aged less than five years, one of the five most common causes of infant and child deaths, stood at 6.5 in 1998. Using data from the 1998 South African Demographic and Health Survey, this paper examines the mechanisms of this racial disparity. The research confirms the presence of persistent racial inequalities in access to safe drinking-water and sanitation and in maternal education and household wealth, with the black population constituting the most disadvantaged group. While the living environment and access to safe drinking-water explain the excessive risk of diarrhoea among the black population compared to the coloured and Indian populations, the excessive risk of diarrhoea among the black population compared to the white population cannot be explained by disparities in the living environment, hygiene levels, and socioeconomic factors.

Aim: To identify the reasons for the fostering of children, and to describe their feeding practices and assess their health and nutritional status., Methods: Forty-six pairs of mothers and their young foster children (up to 24 mo of age) were interviewed in a cross-sectional study in the urban slums of Dhaka, Bangladesh. Another 82 pairs of mothers and their biological children of a similar age group were interviewed for comparison., Results: Sixty-five percent of the children were fostered because of the death of their biological mothers. Eighty-three percent of the biological mothers died because of complications during delivery or the immediate postpartum period and the remainder died after the postpartum period of diseases unrelated to their pregnancies. More than half (52%) of the foster mothers were childless and a quarter (24%) fostered children for reasons of gender preference. Almost a quarter (24%) of the children were placed in foster homes because of extreme parental poverty. Divorce or separation of the biological parents accounted for only 7% of children fostered. Approximately 90% of the foster children were given animal and/or formula milk in their first month of life while all children in the comparison group were given breast milk. Among the foster children, 58% were given semisolid or solid food before completion of 4 mo compared with 14% in the comparison group. Significantly more children in the foster group suffered from diarrhoea and acute respiratory infection than in the comparison group., Conclusion: Maternal death, poverty and childlessness and child gender preference of foster mothers were important factors in fostering of children in the study group. Inappropriate feeding practices compounded by diseases may have contributed to the poor nutritional status of the foster children.