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COVID-19 vaccination reduces SARS-CoV-2 infection and transmission. However, evidence is emerging on the degree of protection across variants and in high-transmission settings. To better understand the protection afforded by vaccination specifically in a high-transmission setting, we examined household transmission of SARS-CoV-2 during a period of high community incidence with predominant SARS-CoV-2 B.1.1.7 (Alpha) variant, among vaccinated and unvaccinated contacts.We conducted a household transmission investigation in San Diego County, California, and Denver, Colorado, during January-April 2021. Households were enrolled if they had at least one person with documented SARS-CoV-2 infection. We collected nasopharyngeal swabs, blood, demographic information, and vaccination history from all consenting household members. We compared infection risks (IRs), RT-PCR cycle threshold values, SARS-CoV-2 culture results, and antibody statuses among vaccinated and unvaccinated household contacts.We enrolled 493 individuals from 138 households. The SARS-CoV-2 variant was identified from 121/138 households (88%). The most common variants were Alpha (75/121, 62%) and Epsilon (19/121, 16%). There were no households with discordant lineages among household members. One fully vaccinated secondary case was symptomatic (13%); the other 5 were asymptomatic (87%). Among unvaccinated secondary cases, 105/108 (97%) were symptomatic. Among 127 households with a single primary case, the IR for household contacts was 45% (146/322; 95% Confidence Interval [CI] 40-51%). The observed IR was higher in unvaccinated (130/257, 49%, 95% CI 45-57%) than fully vaccinated contacts (6/26, 23%, 95% CI 11-42%). A lower proportion of households with a fully vaccinated primary case had secondary cases (1/5, 20%) than households with an unvaccinated primary case (66/108, 62%).Although SARS-CoV-2 infections in vaccinated household contacts were reported in this high transmission setting, full vaccination protected against SARS-CoV-2 infection. These findings further support the protective effect of COVID-19 vaccination and highlight the need for ongoing vaccination among eligible persons.

SUMMARYIn March 2002, an outbreak ofSalmonellaEnteritidis (SE) infections occurred at a convention centre in Dallas, Texas and continued for 6 weeks. We conducted epidemiological studies, obtained clinical and environmental cultures, and interviewed employees to identify risk factors for infection. From 17 March–25 April 2002, the implicated hotel kitchen catered 41 multi-day conferences attended by 9790 persons. We received 617 illness reports from residents of 46 states. Sauces or items served with sauces were implicated in three cohort studies. SE phage-type 8 was identified as the agent. Eleven food service employees, including one who prepared sauces and salsa, had stool cultures that yielded SE. Although the original source was not determined, prolonged transmission resulted in the largest food handler-associated outbreak reported to date, affecting persons from 46 US states. Transmission ended with implementation of policies to screen food handlers and exclude those whose stool cultures yielded salmonellas.

Background: Dengue is caused by an arthropod-borne flavivirus. Infection can be either primary or secondary based on serology, with each stage of the disease characterized by specific serological conversion and antibody formation. Further study is needed to fully identify the factors associated with and predisposing to dengue infection. The objective of this study was to identify socio-demographic factors associated with the prevalence of dengue serotypes in Kassala State in the eastern part of Sudan in 2011. Methods: This was a cross-sectional community-based study with 530 participants who were randomly selected through multi-stage cluster sampling. Dengue serotype prevalence was determined using capture Enzyme-linked immunosorbent assay (ELISA). ELISA IgG. A multivariate logistic regression model was designed to measure the strength of associations between socio-demographic factors and dengue serotype prevalence. All participants who tested negative for dengue were used as the statistical reference group. Results: From this study, the prevalence of dengue in Kassala was estimated to be 9.4 % (95 % CI: 7.1–12.3). Lack of knowledge about dengue fever disease (OR 2.8, 95 % CI: 1.24–6.53) and a household density of more than 3 people per room (OR 2.1, 95 % CI: 1.06–4.09) were the most important factors associated with dengue infection among the study population. Conclusions: Community-oriented interventions are needed to modify existing social behaviors to reduce the risk of dengue in the eastern part of Sudan. Additional studies are also required in this field.

Background In June 1998, we investigated one of the largest foodborne outbreaks of enterotoxigenic Escherichia coli gastroenteritis reported in the United States. Methods We conducted cohort studies of 11 catered events to determine risk factors for illness. We used stool cultures, polymerase chain reaction, and serologic tests to determine the etiologic agent, and we conducted an environmental inspection to identify predisposing conditions and practices at the implicated establishment. Results During 5-7 June, the implicated delicatessen catered 539 events attended by >16,000 people. Our epidemiological study of 11 events included a total of 612 attendees. By applying the median prevalence of illness (20%) among events with ill attendees to the total number of events with any ill attendees, we estimate that at least 3300 persons may have developed gastroenteritis during this outbreak. Multiple food items (potato salad, macaroni salad, egg salad, and watermelon) were associated with illness, all of which required extensive handling during preparation. Enterotoxigenic Escherichia coli serotype O6:H16 producing heat-labile and heat-stable toxins was isolated from the stool specimens from 11 patients. Eight patients with positive stool culture results, 11 (58%) of 19 other symptomatic attendees, and 0 (0%) of 17 control subjects had elevated serum antibody titers to E. coli O6 lipopolysaccharide. The delicatessen had inadequate hand-washing supplies, inadequate protection against back siphonage of wastewater in the potable water system, a poorly draining kitchen sink, and improper food storage and transportation practices. Conclusions In the United States, where enterotoxigenic Escherichia coli is an emerging cause of foodborne disease, enterotoxigenic Escherichia coli should be suspected in outbreaks of gastroenteritis when common bacterial or viral enteric pathogens are not identified.

Salmonella enterica serotype Enteritidis (SE) is a common cause of foodborne illness in the United States. Foods prepared with raw shell eggs have often been associated with SE outbreaks. The federal government published the Egg Safety Action Plan in December 1999 that called for reduction of egg-preparation practices that may contribute to the survival and proliferation of SE. In seven states, an interview and brief site evaluation of 153 restaurants that prepare eggs during all hours of operation was conducted by the Environmental Health Specialists Network to determine the prevalence of such practices. Fifty-four percent (83 of 153) of restaurants pooled raw shell eggs not intended for immediate service. These pooled eggs were held a median of 4 h for scrambled eggs, 5.5 h for omelets, and 6 h for pancakes and French toast. Nearly 26% (39 of 152) of restaurants reported storing eggs at room temperature, and 5% (7 of 152) stored eggs on ice or in cold-water baths before cooking. Generally, eggs were cooked to 72 to 83 degrees C, which is above the recommended final cook temperature of 63 to 68 degrees C. Employees reported sanitizing utensils used to prepare eggs less than once every 4 h in 42% (57 of 136) of restaurants. Several areas were identified in which further emphasis might reduce egg-associated SE infections in accordance with Healthy People 2010 goals.

Summary Background Dengue virus is the most serious mosquito-borne viral threat to public health and no vaccines or antiviral therapies are approved for dengue fever. The tetravalent DENVax vaccine contains a molecularly characterised live attenuated dengue serotype-2 virus (DENVax-2) and three recombinant vaccine viruses expressing the prM and E structural genes for serotypes 1, 3, and 4 in the DENVax-2 genetic backbone. We aimed to assess the safety and immunogenicity of tetravalent DENVax formulations. Methods We undertook a randomised, double-blind, phase 1, dose-escalation trial between Oct 11, 2011, and Nov 9, 2011, in the Rionegro, Antioquia, Colombia. The first cohort of participants (aged 18–45 years) were randomly assigned centrally, via block randomisation, to receive a low-dose formulation of DENvax, or placebo, by either subcutaneous or intradermal administration. After a safety assessment, participants were randomly assigned to receive a high-dose DENVax formulation, or placebo, by subcutaneous or intradermal administration. Group assignment was not masked from study pharmacists, but allocation was concealed from participants, nurses, and investigators. Primary endpoints were frequency and severity of injection-site and systemic reactions within 28 days of each vaccination. Secondary endpoints were the immunogenicity of DENVax against all four dengue virus serotypes, and the viraemia due to each of the four vaccine components after immunisation. Analysis was by intention to treat for safety and per protocol for immunogenicity. Because of the small sample size, no detailed comparison of adverse event rates were warranted. The trial is registered with ClinicalTrials.gov, number NCT01224639. Findings We randomly assigned 96 patients to one of the four study groups: 40 participants (42%) received low-dose vaccine and eight participants (8%) received placebo in the low-dose groups; 39 participants (41%) received high-dose vaccine, with nine (9%) participants assigned to receive placebo. Both formulations were well tolerated with mostly mild and transient local or systemic reactions. No clinically meaningful differences were recorded in the overall incidence of local and systemic adverse events between patients in the vaccine and placebo groups; 68 (86%) of 79 participants in the vaccine groups had solicited systemic adverse events compared with 13 (76%) of 17 of those in the placebo groups. By contrast, 67 participants (85%) in the vaccine group had local solicited reactions compared with five (29%) participants in the placebo group. Immunisation with either high-dose or low-dose DENVax formulations induced neutralising antibody responses to all four dengue virus serotypes; 30 days after the second dose, 47 (62%) of 76 participants given vaccine seroconverted to all four serotypes and 73 (96%) participants seroconverted to three or more dengue viruses. Infectious DENVax viruses were detected in only ten (25%) of 40 participants in the low-dose group and 13 (33%) of 39 participants in the high-dose group. Interpretation Our findings emphasise the acceptable tolerability and immunogenicity of the tetravalent DENVax formulations in healthy, flavivirus-naive adults. Further clinical testing of DENVax in different age groups and in dengue-endemic areas is warranted. Funding Takeda Vaccines.

Introduction: Tissue Engineering is a new methodology for addressing meniscal injury or loss. Synovium may be an ideal source of cells for in vitro meniscal fibrocartilage formation, however, favorable in vitro culture conditions for synovium must be established in order to achieve this goal. The objective of this study was to determine cellularity, cell distribution, and extracellular matrix (ECM) formation of equine fibroblast-like synoviocytes (FLS) cultured on synthetic scaffolds, for potential application in synovium-based meniscal tissue engineering. Scaffolds included open-cell poly-L-lactic acid (OPLA) sponges and polyglycolic acid (PGA) scaffolds cultured in static and dynamic culture conditions, and PGA scaffolds coated in poly-L-lactic (PLLA) in dynamic culture conditions. Materials and Methods: Equine FLS were seeded on OPLA and PGA scaffolds, and cultured in a static environment or in a rotating bioreactor for 12 days. Equine FLS were also seeded on PGA scaffolds coated in 2% or 4% PLLA and cultured in a rotating bioreactor for 14 and 21 days. Three scaffolds from each group were fixed, sectioned and stained with Masson’s Trichrome, Safranin-O, and Hematoxylin and Eosin, and cell numbers and distribution were analyzed using computer image analysis. Three PGA and OPLA scaffolds from each culture condition were also analyzed for extracellular matrix (ECM) production via di-methylmethylene blue (sulfated glycosaminoglycan) assay and hydroxyproline (collagen) assay. PLLA coated PGA scaffolds were analyzed using double stranded DNA quantification as a reflection of cellularity and confocal laser microscopy in a fluorescent cell viability assay. Results: The highest cellularity occurred in PGA constructs cultured in a rotating bioreactor, which also had a mean sulfated glycosaminoglycan content of 22.3μg per scaffold. PGA constructs cultured in static conditions had the lowest cellularity. Cells had difficulty adhering to OPLA and the PLLA coating of PGA scaffolds; cellularity was inversely proportional to the concentration of PLLA used. PLLA coating did not prevent dissolution of the PGA scaffolds. All cell scaffold types and culture conditions produced non-uniform cellular distribution. Discussion/ Conclusion: FLS-seeding of PGA scaffolds cultured in a rotating bioreactor resulted in the most optimal cell and matrix characteristics seen in this study. Cells grew only in the pores of the OPLA sponge, and could not adhere to the PLLA coating of PGA scaffold, due to the hydrophobic property of PLA. While PGA culture in a bioreactor produced measureable GAG, no culture technique produced visible collagen. For this reason, and due to the dissolution of PGA scaffolds, the culture conditions and scaffolds described here are not recommended for inducing fibrochondrogenesis in equine FLS for meniscal tissue engineering.

Dengue vaccines are currently in development and policymakers need appropriate economic studies to determine their potential financial and public health impact. We searched five databases (PubMed, EMBASE, LILAC, EconLit, and WHOLIS) to identify health economics studies of dengue. Forty-three manuscripts were identified that provided primary data: 32 report economic burden of dengue and nine are comparative economic analyses assessing various interventions. The remaining two were a willingness-to-pay study and a policymaker survey. An expert panel reviewed the existing dengue economic literature and recommended future research to fill information gaps. Although dengue is an important vector-borne disease, the economic literature is relatively sparse and results have often been conflicting because of use of inconsistent assumptions. Health economic research specific to dengue is urgently needed to ensure informed decision making on the various options for controlling and preventing this disease.

Background Dengue fever is a virus infection that is spread by the Aedes aegypti mosquito and can cause severe disease especially in children. Dengue fever is a major problem in tropical and sub-tropical regions of the world. Methodology/Principal Findings We invited dengue experts from around the world to attend meetings to discuss dengue surveillance. We reviewed literature, heard detailed reports on surveillance programs, and shared expert opinions. Results Presentations by 22 countries were heard during the 2.5 day meetings. We describe the best methods of surveillance in general, the stakeholders in dengue surveillance, and the steps from mosquito bite to reporting of a dengue case to explore how best to carry out dengue surveillance. We also provide details and a comparison of the dengue surveillance programs by the presenting countries. Conclusions/Significance The experts provided recommendations for achieving the best possible data from dengue surveillance accepting the realities of the real world (e.g., limited funding and staff). Their recommendations included: (1) Every dengue endemic country should make reporting of dengue cases to the government mandatory; (2) electronic reporting systems should be developed and used; (3) at minimum dengue surveillance data should include incidence, hospitalization rates, deaths by age group; (4) additional studies should be completed to check the sensitivity of the system; (5) laboratories should share expertise and data; (6) tests that identify dengue virus should be used in patients with fever for four days or less and antibody tests should be used after day 4 to diagnose dengue; and (7) early detection and prediction of dengue outbreaks should be goals for national surveillance systems., Author Summary The Pediatric Dengue Vaccine Initiative organized Dengue Prevention Boards in the Asia-Pacific and the Americas regions consisting of dengue experts from endemic countries. Both Boards convened meetings to review issues in surveillance. Through presentations, facilitated discussions, and surveys, the Boards identified best practices in dengue surveillance including: (1) Dengue should be a notifiable disease in endemic countries; (2) World Health Organization regional case definitions should be consistently applied; (3) electronic reporting systems should be developed and used broadly to speed delivery of data to stakeholders; (4) minimum reporting should include incidence rates of dengue fever, dengue hemorrhagic fever, dengue shock syndrome, and dengue deaths, and hospitalization and mortality rates should be reported by age group; (5) periodic additional studies (e.g., capture/recapture) should be conducted to assess under-detection, under-reporting, and the quality of surveillance; (6) laboratory methods and protocols should be standardized; (7) national authorities should encourage laboratories to develop networks to share expertise and data; and (8) RT-PCR and virus isolation (and possibly detection of the NS1 protein) are the recommended methods for confirmation of an acute dengue infection, but are recommended only for the four days after onset of fever—after day 4, IgM-capture enzyme-linked immunosorbent assay is recommended.

Background Periodic outbreaks of dengue fever occur in the United States Virgin Islands. In June 2005, an outbreak of dengue virus (DENV) serotype-2 with cases of dengue hemorrhagic fever (DHF) was detected in St. Croix, US Virgin Islands. The objective of this report is to describe this outbreak of DENV-2 and the findings of a case-control study examining risk factors for DHF. Methodology/Principal Findings This is the largest dengue outbreak ever recorded in St. Croix, with 331 suspected dengue cases reported island-wide during 2005 (62.2 cases/10,000 population); 54% were hospitalized, 21% had at least one hemorrhagic manifestation, 28% had thrombocytopenia, 5% had DHF and 1 patient died. Eighty-nine laboratory-positive hospitalized patients were identified. Of these, there were 15 (17%) who met the WHO criteria for DHF (cases) and 74 (83%) who did not (controls). The only variable significantly associated with DHF on bivariate or multivariable analysis was age, with an adjusted odds ratio (95% confidence interval) of 1.033 (1.003,1.064). Conclusions/Significance During this outbreak of DENV-2, a high proportion of cases developed DHF and increasing age was significantly associated with DHF.

We examined the public health effects of the Northeast blackout of August 2003 and the emergency response to the blackout by the New York City Department of Health and Mental Hygiene (DOHMH). We reviewed departmental documents from the DOHMH Emergency Operations Center and surveyed DOHMH employees to identify deficiencies in the response and elicit suggestions for improvement. DOHMH deployed its all-hazards, scalable public health Incident Management System to respond to several impacts: ( 1) failure of multiple hospital emergency generators; ( 2) patients dependent on electrically powered equipment; ( 3) loss of electronic data input to the DOHMH syndromic surveillance system from hospital emergency departments; ( 4) potential for vaccine spoilage due to loss of refrigeration; ( 5) beach contamination with untreated sewage; ( 6) heat-related health effects and increase of foodborne disease; and ( 7) potential for an increased rodent population as a result of increased amounts of discarded perishables. Areas identified for improvement included communications during the event, DOHMH dependence on an external source of electricity, facility management during the response, and lack of readily available and appropriate emergency supplies.

Diarrhea is a major cause of preventable illness in sub-Saharan Africa. Although most cases of bacterial gastroenteritis do not require antimicrobial treatment antimicrobial use is widespread. We examined the bacterial causes of diarrhea and monitored antimicrobial susceptibilities of isolates through clinic-based surveillance in a rural Kenyan community. From May 1997 through April 2003 diarrheal stool samples from persons presenting to 4 sentinel health centers were cultured by standard techniques for routine bacterial enteric pathogens for which antimicrobial susceptibilities were determined. A random subset of specimens was also evaluated for diarrheagenic Escherichia coli. Among stool specimens from 3445 persons 1092 (32%) yielded at least 1 bacterial pathogen. Shigella species was most commonly isolated (responsible for 16% of all illnesses; 54% of isolates were Shigella flexneri). Campylobacter species and diarrheagenic E. coli predominated among children aged < 5 years and were progressively replaced by Shigella species with increasing age. With the exception of Campylobacter species susceptibility to the antimicrobials used most widely in the community was low: < 40% for all isolates tested and < 25% for Shigella species. Most persons were treated with an antimicrobial to which their isolate was resistant. Susceptibility to specific antimicrobials was inversely proportional to the frequency with which they were prescribed. The utility of available antimicrobials for treating bacterial diarrhea in rural western Kenya is substantially limited by reduced susceptibility. More judicious use of appropriate antimicrobials is warranted. Efforts to prevent illness through provision of clean water improved hygiene and vaccine development should be strengthened. (authors)

Purpose Enterotoxigenic Escherichia coli (ETEC) is traditionally recognized as a common cause of traveler's diarrhea, but is becoming a more frequent cause of foodborne disease outbreaks in the United States. It is important for public health practitioners and clinicians to be aware of ETEC as a domestic cause of gastroenteritis. We investigated a foodborne disease outbreak to understand the epidemiology of ETEC in this setting. Methods We conducted a cohort study of 63 employees of Company A. A case was defined as an employee who experienced diarrhea or vomiting or fever and cramps after eating a catered meal at Company A from August 14th-15th. A standardized questionnaire was administered to cases and controls. Results Of 63 employees, 36 met the case definition (Attack Rate=57.1%). Diarrhea (94%) and cramps (74%) were common, whereas vomiting was not (3%). Mean duration of illness was 2.7 days. Coleslaw at the August 15th lunch was significantly associated with illness (Odds ratio=4.4, 95% CI=1.1-17). Stool specimens were positive for heat-stable enterotoxin-producing E. coli O169:H41. Contamination likely occurred at the point of service. Conclusions This outbreak illustrates the changing epidemiology of enterotoxigenic E. coli and the importance for healthcare practitioners to consider ETEC as a potential cause of domestically acquired gastroenteritis.

To the Editor. — Escherichia coli O157:H7 is a common cause of bloody diarrhea and postdiarrheal hemolytic uremic syndrome (HUS) in the United States.1 However, in many hospital laboratories, a routine stool culture does not include testing for E coli O157:H7.2 Furthermore, some studies suggest that the empiric use of antibiotics in children with E coli O157:H7 infections may increase the risk of HUS.3,4 During a recent investigation of E coli O157:H7 infections and HUS, we reviewed the culturing and antibiotic-prescribing practices at a metropolitan children’s hospital in Texas. We reviewed all emergency department and urgent care records from July 6 to 29, 2000. Of the 2460 records reviewed, 287 (12%) recorded a diagnosis of acute diarrheal illness in a child ≤18 years of age (Fig …

Recent events have drawn attention to cases of inhalational and cutaneous anthrax associated with contaminated mail. Gastrointestinal anthrax, the disease caused by ingestion of Bacillus anthracis organisms, has rarely been reported in the United States. This review provides background information on the gastrointestinal form of the disease. We describe the clinical course of gastrointestinal anthrax, outline current therapy, review the microbiology of B anthracis, examine the epidemiology of natural outbreaks, discuss considerations regarding deliberate contamination, and summarize existing literature on the inactivation of spores present in food and water.

In December 2000, physicians in the Republic of the Marshall Islands reported the first known outbreak of Vibrio cholerae O1 infection (biotype El Tor, serotype Ogawa) from this country. In a matched case-control study on Ebeye Island, patients with cholera (n=53) had greater odds than persons without cholera (n=104) to have drunk adequately chlorinated water collected from a US military installation on neighboring Kwajalein Island and transported back to Ebeye (matched odds ratio [MOR], 8.0; P=.01). Transporting or storing drinking water in a water cooler with a spout and a tight-fitting lid was associated with reduced odds of illness (MOR, 0.24; P.01), as was drinking bottled water (MOR, 0.08; P.01), boiled water (MOR, 0.47; P=.02), or water flavored with powdered drink mixes (MOR, 0.18; P.01). No cases of cholera were reported among Kwajalein residents. This outbreak highlights the critical importance of handling and storing drinking water safely, especially during outbreaks of gastrointestinal illness.

Raw sprouts have been implicated in a number of foodborne disease outbreaks. Because contaminated seeds are usually responsible, many sprout producers attempt to disinfect seeds before germination and detect sprout contamination during production. In March 2001, we detected an increased number of Salmonella serotype Kottbus isolates in California. Overall, we identified 31 cases from three western states. To identify the cause, we conducted a case-control study with the first 10 identified case-patients matched to 20 controls by age, sex, and residential area. Our case-control study found illness to be statistically associated with alfalfa sprout consumption. The traceback investigation implicated a single sprouter, where environmental studies yielded Salmonella Kottbus from ungerminated seeds and floor drains within the production facility. Pulsed-field gel electrophoresis patterns of all patient, seed, and floor drain Salmonella Kottbus isolates were indistinguishable. Most implicated sprouts were from seeds that underwent heat treatment and soaking with a 2,000-ppm sodium hypochlorite solution rather than the Food and Drug Administration (FDA)-recommended 20,000-ppm calcium hypochlorite soak. Other implicated seeds had been soaked in a calcium hypochlorite solution that, when tested, measured only 11,000 ppm. The outbreak might have been averted when screening tests of sprout irrigation water detected Salmonella in January; however, confirmatory testing of these samples was negative (but testing improperly utilized refrigerated irrigation water). Producers should use the enrichment broth of positive screening samples, not refrigerated irrigation water, for confirmatory testing. Until other effective disinfection technologies are developed, producers should adhere to FDA recommendations for sprout seed disinfection.

After Hurricane Jeanne in September 2004, surveillance for mosquitoborne diseases in Gonaives, Haiti, identified 3 patients with malaria, 2 with acute dengue infections, and 2 with acute West Nile virus infections among 116 febrile patients. These are the first reported human West Nile virus infections on the island of Hispaniola.

Investigate differences in the infectious aetiology, health seeking behaviour, and provider practices with regard to diarrhoeal illness among children presenting to urban versus rural clinics in Western Kenya.Laboratory-based, passive surveillance.The urban portion of the study was conducted at the paediatric outpatient clinic of Nyanza Provincial Hospital in Kisumu. The rural portion of the study was conducted at four outpatient clinics in the Asembo Bay community approximately 20 kilometers west of Kisumu.Children aged less than five years presenting to medical facilities for the treatment of diarrhoea from October 2001-October 2003 at the urban site and May 1997-April 2003 for the rural sites.Among the 1303 urban and 1247 rural specimens collected, 24% of specimens yielded a bacterial pathogen (24% urban, 25% rural). Campylobacter was the predominant bacterial pathogen (17% urban, 15% rural), followed by Shigella and nontyphoidal Salmonella (both 4% urban and 5% rural). In both communities, susceptibilities of these pathogens to the most commonly prescribed antibiotics was low (or = 50%); 70% of all episodes of diarrhoea were prescribed antibiotic treatment. Urban health practitioners prescribed fewer antibiotics, chose drugs more likely to be effective, and were more likely to prescribe oral rehydration therapy for bloody diarrhoea.Most characteristics of diarrhoeal disease and their causes were similar in paediatric patients presenting to urban and rural clinics. Urban providers were more compliant with WHO recommendations.

Background The average annual reported dengue incidence in Cambodia is 3.3/1,000 among children < 15 years of age (2002–2007). To estimate the economic burden of dengue, accurate cost-of-illness data are essential. We conducted a prospective, community-based, matched case-control study to assess the cost and impact of an episode of dengue fever and other febrile illness on households in rural Cambodia. Methods In 2006, active fever surveillance was conducted among a cohort of 6,694 children aged ≤ 15 years in 16 villages in Kampong Cham province, Cambodia. Subsequently, a case-control study was performed by individually assigning one non-dengue febrile control from the cohort to each laboratory-confirmed dengue case. Parents of cases and controls were interviewed using a standardized questionnaire to determine household-level, illness-related expenditures for medical and non-medical costs, and estimated income loss (see Additional file 1). The household socio-economic status was determined and its possible association with health seeking behaviour and the ability to pay for the costs of a febrile illness. Results Between September and November 2006, a total of 60 household heads were interviewed: 30 with dengue-positive and 30 with dengue-negative febrile children. Mean total dengue-related costs did not differ from those of other febrile illnesses (31.5 vs. 27.2 US$, p = 0.44). Hospitalization almost tripled the costs of dengue (from 14.3 to 40.1 US$) and doubled the costs of other febrile illnesses (from 17.0 to 36.2 US$). To finance the cost of a febrile illness, 67% of households incurred an average debt of 23.5 US$ and higher debt was associated with hospitalization compared to outpatient treatment (US$ 23.1 vs. US$ 4.5, p < 0.001). These costs compared to an average one-week expenditure on food of US$ 9.5 per household (range 2.5–21.3). In multivariate analysis, higher socio-economic status (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.4–13.2), duration of fever (OR 2.1; 95%CI 1.3–3.5), and age (OR 0.8; 95%CI 0.7–0.9) were independently associated with hospitalization. Conclusion In Cambodia, dengue and other febrile illnesses pose a financial burden to households. A possible reason for a lower rate of hospitalization among children from poor households could be the burden of higher illness-related costs and debts.