The association between malnutrition and diarrhoea in rural Bangladesh.

The interaction between diarrhoeal disease and nutritional status measured by anthropometry was investigated in approximately 1000 children aged 1 to 4 years during April-December 1976 in a rural area of Bangladesh. Data on diarrhoeal disease were provided by the mothers interviewed at seven-day intervals. Weight and height data were collected bimonthly. Children classified using anthropometric criteria--weight-for-age, height-for-age, and weight-for-height--were prospectively evaluated for incidence and duration of diarrhoea during a short (two-month) period and a long (eight-month) period. Incidence of diarrhoea was not found to be related to nutritional status measured by any of the anthropometric criteria for any of the periods. But duration of diarrhoea was found to be related consistently to nutritional status measured by weight-for-age and weight-for-height. Diarrhoea in the short term affected weight increment in the short term, but not in the long term and did not affect height increment for any of these periods. Diarrhoea in the long term affected both weight increment and height increment in the long term.

Cellular immune competence and diarrheal morbidity in malnourished Bangladeshi children: a prospective field study.

A year-long prospective study of 152 Bangladeshi children with mild to moderate protein-calorie malnutrition related nutritional status and cellular immune defects to morbidity due to diarrheal, respiratory, and febrile diseases. In children older than 36 mo, wasting correlated with skin test anergy to three recall antigens and with inability to initiate hypersensitivity to dinitrochlorobenzene. In this older age group, anergy was associated with a 58% increased attack rate and an 83% increased duration of diarrheal diseases but not with febrile or respiratory infections. In stepwise regression analysis, this anergy effect was independent of the small negative impact of poorer nutritional status on morbidity. Ninety-three percent of diarrheal illnesses lasting at least 14 d were among anergic children. Cellular immune incompetence, indicated by anergy of unknown etiology, is associated with increased diarrheal morbidity and may promote the vicious cycle of repeated infections and deteriorating nutritional status.

PIP: A year long prospective study of 152 Bangladeshi children with mild to moderate protein-calorie malnutrition related nutritional status and cellular immune defects to morbidity due to diarrheal, respiratory, and febrile diseases. In children older than 36 months, wasting correlated with skin test anergy to 3 recall antigens and with inability to initiate hypersensitivity to dinitrochlorobenzene. In this older age group, anergy was associated with a 58% increased attack rate and an 83% increased duration of diarrheal diseases but not with febrile or respiratory infections. In stepwise regression analysis, this anergy effect was independent of small negative impact of poorer nutritional status on morbidity. 93% of diarrheal illnesses lasting at least 14 days were among anergic children. Cellular immune incompetence, indicated by anergy of unknown etiology, is associated with increased diarrheal morbidity and may promote the vicious cycle of repeated infections and deteriorating nutritional status.

Alternative anthropometric indicators of mortality.

The ability of anthropometric indicators, weight-for-age, height-for-age, weight-for-height, weight velocity, and height velocity to discriminate mortality during a one-year period is examined for three time frames beginning in different seasons. Data on approximately 1,000 children of one to four years of age come from the Matlab, International Centre for Diarrhoeal Disease Research, Bangladesh. The indicators' mortality-discriminating power is assessed in terms of the magnitude of difference between the mean indicator values of living and dead children expressed in standard deviation units and of the maximum sum of sensitivity and specificity. The indicators' mortality curve by nutritional status shows the discriminating power visually; the t test indicates its statistical significance. Weight-for-age and height-for-age perform better than weight velocity and height velocity as discriminators of mortality during a one-year period. The ability of weight and height velocity to discriminate short-term mortality is examined by comparing the mean velocity of the last two bimonthly intervals of the dead children. Weight velocity is likely to be a good indicator of short-term mortality.

Summary of clinical trials of inactivated influenza vaccine - 1978.

This report summarizes the clinical trials of the A/USSR/77 (H1N1) influenza vaccines performed in 1978. A total of 2,091 subjects participated in these trials. The results of these clinical trials indicated that two doses of H1N1 viral antigen were necessary to produce serum titers of hemagglutinin-inhibiting (HAI) antibody of greater than 1:40 in 80% or more of the test subjects younger than 25 years of age, who were unlikely to have experienced natural infection during the earlier period of prevalence of H1N1 virus (1947-1957). Only one dose of the A/Texas/77 (H3N2) or B/Hong Kong/72 antigen was necessary to stimulate equivalent titers of HAI antibody in serum. Thus, previous natural exposure to H1N1 viruses primed individuals 26 years of age or older to respond to H1N1 antigens. No major differences in antigenicity were noted between whole-virus and split-virus vaccines. No differences in reaction indexes measuring systemic reactions were noted when vaccine types were compared. Only one vaccine was associated with a reaction index appreciably higher than that of placebo. The relatively uniform antibody responses observed were attributed to the newer methods of vaccine standardization introduced after the clinical trials in 1976. No cases of vaccine-related neurological problems, including Guillain-Barré syndrome, were found during these trials. Vaccines containing 7-21 micrograms of each viral antigen were antigenic and were well tolerated.

Patterns of Shigella infection in families in rural Bangladesh.

To assess the mode of transmission of Shigella infection in rural Bangladesh, questionnaire and culture surveys were conducted in baris (neighborhoods) where persons with diarrhea associated with Shigella infection and index controls with non-Shigella diarrhea lived. Nineteen percent of persons in Shigella baris and 7% of persons in control baris were infected during the survey periods (P less than 0.001). The prevalence of Shigella infection was highest for children 1-9 years of age and for females than 39 years and was not related to socioeconomic status, family size or household crowding. Use of surface water for drinking was not a risk factor for Shigella infection; in fact, use of river water was more frequent in control baris. Both household and bari contacts of Shigella index cases frequently excreted different serotypes from that excreted by the person with the index case. In Shigella baris, families with infection were significantly more likely than uninfected families to have a history of an overnight stay away from home by a family member during the previous week. These observations suggest there were multiple introductions of Shigella into some families and that the epidemiology of Shigella infection for families in rural Bangladesh differs from that observed for families living in more industrialized countries.

Epidemiology of eltor cholera in rural Bangladesh: importance of surface water in transmission.

In order to define the role of water used for drinking, cooking, bathing, and washing in the transmission of Vibrio cholerae biotype eltor infections in an area with endemic cholera, surveillance was initiated in neighbourhoods with a culture-confirmed cholera index case and others with index cases with non-cholera diarrhoea as controls. In neighbourhoods with cholera infection, 44% of surface water sources were positive for V. cholerae, whereas only 2% of surface sources were positive in control neighbourhoods. Canals, rivers, and tanks were most frequently positive. There was an increased risk of infection for families using water from culture-positive sources for drinking, cooking, bathing, or washing and for those using water sources used by index families for drinking, cooking or bathing. Analysis of the results for individuals showed that in this case there was an increased risk of infection associated with using water from culture-positive sources for cooking, bathing, or washing, but not with using water from culture-positive sources for drinking. Individuals who used the same water source as an index family for bathing were more likely to be infected than those using different sources. For families drinking from a culture-negative source, there was an association between infection and bathing in a positive source. For families using a different bathing source from the index family there was an association between infection and drinking from the same source as the index family, and for families using a different drinking source from the index family there was an association between infection and bathing in the same source as the index family. These data suggest that use of surface water is important in the transmission of V. cholerae and that, in addition to providing safe drinking water, education regarding the risk of transmission of infection by water from potentially contaminated sources used for other purposes, especially bathing, may also be necessary to control transmission in areas where eltor cholera is endemic.

Use of tetanus toxoid for the prevention of neonatal tetanus. 1. Reduction of neonatal mortality by immunization of non-pregnant and pregnant women in rural Bangladesh.

PIP: 1 approach to the prevention of tetanus neonatorum (a leading cause of infant death throughout the world) is improving the quality of prenatal, obstetric, and postnatal maternal and child health services. Another complementary approach is the active immunization of women before or during pregnancy with tetanus toxoid. Work in progress at the Matlab field station of the International Center for Diarrheal Disease Research in Bangladesh (ICDDR,B) provided a unique opportunity to study the effectiveness of certain aspects of these 2 strategies. In 1974, during a field trial of cholera toxoid vaccine, 2 injections of an aluminum phosphate tetanus-diphtheria toxoid were provided as a control to a randomly assigned group of nonpregnant women. Beginning in June 1978, a program of immunizing women during pregnancy with aluminum phosphate-absorbed tetanus toxoid was initiated in conjunction with the implementation of a village based maternal and child health and family planning program in half of the same Matlab surveillance area. Throughout the period of these 2 programs, the ICDDR,B maintained an independent, longitudinal, vital registration system, identifying all births and deaths in the study area. In this analysis, all live births registered in the Maternal and Child Health-Family Planning and comparison areas during the September 1, 1978 until December 31, 1979 period were identified. These records were linked with any deaths recorded within 28 days of birth. The acceptance of tetanus vaccination during the 1974 cholera vaccine trial, by the mothers of these live births, was ascertained from the 1974 vaccine registers. The acceptance of vaccination during the 1978-1979 program was obtained from the field registers. For infants whose mothers had received 2 tetanus injections 48-64 months prior to delivery, the neonatal mortality rate was 63.8/l000 live births compared with 78.3/1000 for infants whose mothers did not receive tetanus immunization. Immunization of women with 2 tetanus injections during pregnancy reduced neonatal mortality rates to 42.8/1000, a reduction of 35.5/1000. Mortality on days 4-14 was reduced by about 70%. 1 injection during pregnancy did not appear to provide protection against tetanus neonatorum.^ieng

Synergistic impact of measles and diarrhoea on nutrition and mortality in Bangladesh.

PIP: The association between measles and diarrhea and their effects on weight and mortality were assessed in a prospective household survey in southeast Bangladesh from August 1975 to July 1976. A total 5775 children in 12 villages were checked weekly. Nutritional status was determined by height and weight at 2 month intervals. Measles epidemics occurred in 2 villages. 923 cases of measles were recorded, 97% in children under 10 years. There were 33 deaths within 30 days of the appearance of rash, a case fatality rate of 3.7% among children. Prolonged diarrhea was the most common complication in fatal cases; pneumonia was the next most common complication. In this population, mortality from measles-associated illness was not related to nutritional status, since in a case-control comparison, the children who died did not differ in nutritional status from controls before their illness. In the 2 largest villages, 2% of measles cases not complicated with diarrhea died, compared to 12% who died of diarrhea with measles (p.0005). This 4-fold mortality suggests that measles and diarrhea combine synergistically to increase mortality. Surviving children with prolonged diarrhea and the greatest weight loss failed to catch up in growth compared to their peers. Until an extensive measles vaccination program is initiated in Bangladesh, nutritional intervention should be aimed at young children convalescing from measles.^ieng

Diarrhoeal disease in Bangladesh: epidemiology, mortality averted and costs at a rural treatment centre.

The basic epidemiology of acute diarrhoeal disease seen at a rural Bangladesh hospital in 1975 is reviewed. V. cholerae 01 was isolated from 28% of 1 964 patients. Significant differences in hospitalisation rates were observed between males and females in several age groups. Overall hospital case fatality was 9/1000 cases. We estimate that approximately a quarter to half of the hospitalised patients would have died had no rehydration therapy been available. The region's total mortality was reduced by approximately 7%-15%, at a cost of United States $0.14 per capita. Mortality from acute diarrhoeal diseases was greatly reduced for all age groups, and total mortality and mortality from all diarrhoeal diseases were particularly reduced for young children and young adults. Rehydration therapy used in a field hospital was apparently highly effective in reducing general mortality and mortality from acute diarrhoeal diseases.

A two-year study of bacterial, viral, and parasitic agents associated with diarrhea in rural Bangladesh.

Enteric pathogens associated with diarrhea were studied for two years at a diarrhea treatment center in rural Bangladesh. Enterotoxigenic Escherichia coli (ETEC) was the most frequently identified pathogen for patients of all ages. Rotavirus and ETEC were isolated from approximately 50% and approximately 25%, respectively, of patients less than two years of age. A bacterial or viral pathogen was identified for 70% of these young children and for 56% of all patients with diarrhea. Most ETEC isolates were obtained in the hot dry months of March and April and the hot wet months of August and September. Rotavirus identification peaked in the cool dry months of December and January, but infected patients were found year-round. The low case-fatality rates for patients with watery diarrhea and substantial dehydration further document the usefulness of treating patients with diarrhea with either a glucose- or sucrose-base electrolyte solution such as those used in this treatment center.

Rotavirus gastroenteritis in the Washington, DC, area: incidence of cases resulting in admission to the hospital.

The incidence of rotavirus gastroenteritis in infants and children that required admission to the hospital was estimated for a defined population of approximately 105,000 individuals, including 29,000 children aged 15 years or younger whose primary health care was provided by Group Health Association, Inc, a health maintenance organization in the Washington, DC, area. From January 1977 through March 1979, almost all infants and children in this age group who required hospitalization for gastroenteritis were studied for evidence of infection with human rotavirus (HRV) and other agents. On the average, one in 272 (3.7/1,000) infants less than 12 months old and one in 451 (2.2/1,000) children aged 13 through 24 months were hospitalized for HRV disease each winter. The incidence of rotavirus gastroenteritis requiring hospitalization declined precipitously in children after the second birthday and such illness was not detected in children aged 5 years or older. The role of other agents in acute gastroenteritis requring hospitalization was minimal, compared with that of rotavirus.

Reduction of neonatal tetanus by mass immunization of non-pregnant women: duration of protection provided by one or two doses of aluminium-adsorbed tetanus toxoid.

Immunization of non-pregnant women in rural Bangladesh with two doses of aluminium-adsorbed tetanus-diphtheria toxoids reduced neonatal mortality by one-third during a period of 9-32 months after vaccination. The reduction in mortality rate was attributable almost entirely to a 75% lower mortality rate among 4-14-day-old infants, when tetanus was the predominant cause of death.In the period up to 20 months following vaccination, the reduction in deaths among 4-14-day-old infants after a single dose of tetanus-diptheria toxoids was about the same as that after two doses. However, beyond 20 months a single dose did not appear to provide protection.