This document summarizes a study on rotavirus and other causes of diarrhea in children in a southern Indian community. The study followed 452 newborn infants for 3 years, monitoring diarrhea incidence through twice weekly home visits. A total of 1856 diarrhea episodes were recorded. Rotavirus was found to be the most common cause, associated with 18% of episodes. Other common causes included Giardia (8%) and Aeromonas (4%). Diarrhea incidence was highest in infancy, at 1.6 episodes per child on average over 3 years. Poor hygiene was associated with more severe diarrhea. The study provides valuable community-level data on the etiology and burden of childhood diarrhea in southern India.

1. Journal club
Presentation by dr. c.kannan,
1st year PG
MGMCRI

2. Rotavirus and other Diarrheal Disease in a Birth Cohort
from Southern Indian Community
From Indian pediatrics
Received: May 15, 2015;
Initial review: October 09, 2015;
Accepted: May 05, 2016.

3. AUTHORS
R SARKAR, BP GLADSTONE, JP WARIER,SL SHARMA, U RAMAN,
J MULIYIL AND G KANG
(From Division of Gastrointestinal Sciences, and *Community
Health Department, Christian Medical College, Vellore, TamilNadu,
India.)
Correspondence to:
Dr Gagandeep Kang,
(Division of Gastrointestinal Sciences, Christian Medical College,
Vellore 632 004)

4. Objective is to describe
 Incidence,
 Severity and
 Etiology of diarrheal disease
In infants and young children residing in an urban slum
community in Southern India.

5. Acute diarrheal diseases
 One of the top five causes of morbidity and mortality worldwide,
 Causes 0.52 million deaths annuallyin children under the age of 5 years
 The most common enteropathogens causing diarrhea are
 rotavirus,
 Cryptosporidium spp.,
 Salmonella spp.,
 Campylobacter,
 Shigella,
 diarrheagenic Escherichiacoli,
 calicivirus,
 adenovirus,
 astrovirus and possibly Giardia.
 Rotavirus, norovirus and diarrheagenic Escherichia coli are responsible for more than
half of all diarrheal deaths in under-five children

6. Diarrhoea
 Passage of 3 or more loose watery stools in a 24-
hour period or
 Change in the number or consistency of the stools.
An Episode of Diarrhoea
 At least one day of diarrhoea, preceded and
followed by two or more days without diarrhoea

7. Acute diarrhoea
 Defined as an episode lasting for less than 14 days
Persistent diarrhoea
 Defined as an episode lasting for 14 days or more

8. The Vesikari scale
 Severity of diarrhoea was assessed using the Vesikari scale,
 Originally designed for assessing rotavirus disease presenting to
hospital.
 An episode was considered
 mild - 5 or less,
 moderate - 6-10 and
 severe - 11 or more.

9. Hygiene status of the household
 Recorded for all children at the time of recruitment and
 Thereafter at 6-monthly intervals,
 Using a previously validated questionnaire
 Each household assigned a score ranging from 0 to 21.
 Good (≥13),
 Poor (10-12) and
 Very poor (≤9) hygiene

10. Setting
Three contiguous urban slums in Vellore, Tamil Nadu.
Participants
Children participating in a birth cohort study on diarrheal
disease are 452
Children completed three years of follow-up are 373

11. Work done on
 Diarrheal incidence (obtained by twice weekly home visits)
 Severity of diarrhea (assessed by the Vesikari scoring system)
 Etiological agents associated with diarrhea
 Examination of stool specimens by bacteriologic culture,
 Rotavirus enzyme immunoassay,
 PCR for norovirus and
 Microscopy for parasites).

12. Methods applied on work
 452 newborn infants were recruited from three contiguous urban slums
in Vellore between March 2002 and August 2003.
 They were followed up with twice weekly home visits by field workers, who enquired
about morbidity, until they attained the age of three years.
 Stool samples were collected whenever a child was found to have an episode
of diarrhea.
 During a diarrheal episode, the child was visited on alternate days until resolution.
 Detailed clinical data was collected on the
 onset, duration, frequency,
 color and consistency of stools,
 associated vomiting and fever,
 presence and severity of dehydration, and treatment.
 The Institutional Review Board of Christian Medical College, Vellore, approved the study
and written informed consent was obtained from parents/guardians of all children prior to
enrollment

13. Statistical analysis
 Pathogen-specific incidence rates of diarrhea episodes,
 Season-specific incidence,
 Severity and age at infection for specific diarrheal pathogens were calculated by the
 Number of episodes as the numerator and the
 Total child-years of follow-up as the denominator.
 Factors influencing severity of diarrhea (moderate/severe vs. mild) was assessed by
 logistic regression analysis
 odds ratios with 95% confidence intervals (CI) were calculated

14. Results and interpretations
 1856 episodes in 373 children,
 Samples collected are 1829
 Frequency in age
 1.6 episodes / child on average,
 2.76 episodes in infancy,
 1.28 episodes in 2nd year,
 0.94 episodes in 3rd year,
 Frequency in year
 95 % have one episode in 3 years,
 28 % have more than 6 episodes by the time they reach 3 years
 in 4 months 50% have one episode,
 at 6 months 75 % have more than 1 episode ,
 increased incidence b/w 3-8 months,
 Median duration is 3 days (2-4),
 42%of episodes in 1st year are >3 days,
 29% of episodes in 2nd year are >3 days,
 22%of episodes in 3rd year are >3 days

15.  1833(98.8%)episodes are acute,
 23(1.2%)are persistant,
 Associated symptoms
 vomitting seen in 297 (16%)episodes,
 fever seen in 317(17%)episodes,
 mucus in stool seen in 250(13.5%)episodes,
 bloody in 41(2.2%) episodes,
 Treatments
 antibiotics used in 27.5%,
 antimotility in 14.6%
 ORS given in 1564(87.4%) episodes,
 In 1793 episodes
 58.4%are mild,
 33.4% are moderate,
 8.2% are severe

16.  Antibiotics used
 in 19.1% of mild,
 38% moderate
 and 54.2% of severe episodes,
 Proportion of highest severity is seen in age <6 months is 12%,
 Out of 1829 episodes
 635(35.7%) are a/w 1 or >1 pathogens
 in that 28 % in infancy and
 45% are in late years,
 coinfection with 2 organisms is 88(4.8%)
 with 3 or more organisms is 9(0.5%)
 Out of positive samples
 rotavirus (18%),
 giardia(8%),
 aeromonas(4%),
 cryptosporosis(3%),
 shigella (2%),
 vibrio(1%),

17. Seasonal pattern of diarrheal incidence among children
in the birth cohort, followed from March 2002 to August
2006.

18. WHAT IS ALREADY KNOWN?
• The etiology of diarrhea in hospitalized children is well documented, but community
estimates from longitudinal studies are lacking.
WHAT THIS STUDY ADDS?
• Poor and very poor hygiene status showed a higher risk of getting severe diarrhoea
• Good hygiene practices within the home, such as washing hands with soap before
feeding a child, can reduce the risk of 33% of childhood diarrhea
• Incidence rate of diarrhea was 1.66 episodes per child year for first 3 years of life;
highest incidence (2.76episodes per child year) is seen in infancy.
• As with hospitalized children, rotavirus was the commonest etiological agent
associated with 18% of childhood diarrhea in the community.

19. THANK YOU!!