Soil-Transmitted Helminth Infections and Correlated Risk Factors in Preschool and School-Aged Children in Rural Southwest China

We conducted a survey of 1707 children in 141 impoverished rural areas of Guizhou and Sichuan Provinces in Southwest China. Kato-Katz smear testing of stool samples elucidated the prevalence of ascariasis, trichuriasis and hookworm infections in pre-school and school aged children. Demographic, hygiene, household and anthropometric data were collected to better understand risks for infection in this population. 21.2 percent of pre-school children and 22.9 percent of school aged children were infected with at least one of the three types of STH. In Guizhou, 33.9 percent of pre-school children were infected, as were 40.1 percent of school aged children. In Sichuan, these numbers were 9.7 percent and 6.6 percent, respectively. Number of siblings, maternal education, consumption of uncooked meat, consumption of unboiled water, and livestock ownership all correlated significantly with STH infection. Through decomposition analysis, we determined that these correlates made up 26.7 percent of the difference in STH infection between the two provinces. Multivariate analysis showed that STH infection is associated with significantly lower weight-for-age and height-for-age z-scores; moreover, older children infected with STHs lag further behind on the international growth scales than younger children.     

Prevalence of Dyslipidaemia and Associated Risk Factors in a Rural Population in South-Western Uganda: A Community Based Survey

BackgroundThe burden of dyslipidaemia is rising in many low income countries. However, there are few data on the prevalence of, or risk factors for, dyslipidaemia in Africa.MethodsIn 2011, we used the WHO Stepwise approach to collect cardiovascular risk data within a general population cohort in rural south-western Uganda. Dyslipidaemia was defined by high total cholesterol (TC) ≥ 5.2mmol/L or low high density lipoprotein cholesterol (HDL-C) <1 mmol/L in men, and <1.3 mmol/L in women. Logistic regression was used to explore correlates of dyslipidaemia.ResultsLow HDL-C prevalence was 71.3% and high TC was 6.0%. In multivariate analysis, factors independently associated with low HDL-C among both men and women were: decreasing age, tribe (prevalence highest among Rwandese tribe), lower education, alcohol consumption (comparing current drinkers to never drinkers: men adjusted (a)OR=0.44, 95%CI=0.35-0.55; women aOR=0.51, 95%CI=0.41-0.64), consuming <5 servings of fruit/vegetable per day, daily vigorous physical activity (comparing those with none vs those with 5 days a week: men aOR=0.83 95%CI=0.67-1.02; women aOR=0.76, 95%CI=0.55-0.99), blood pressure (comparing those with hypertension to those with normal blood pressure: men aOR=0.57, 95%CI=0.43-0.75; women aOR=0.69, 95%CI=0.52-0.93) and HIV infection (HIV infected without ART vs. HIV negative: men aOR=2.45, 95%CI=1.53-3.94; women aOR=1.88, 95%CI=1.19-2.97). The odds of low HDL-C was also higher among men with high BMI or HbA1c ≤6%, and women who were single or with abdominal obesity. Among both men and women, high TC was independently associated with increasing age, non-Rwandese tribe, high waist circumference (men aOR=5.70, 95%CI=1.97-16.49; women aOR=1.58, 95%CI=1.10-2.28), hypertension (men aOR=3.49, 95%CI=1.74-7.00; women aOR=1.47, 95%CI=0.96-2.23) and HbA1c >6% (men aOR=3.00, 95%CI=1.37-6.59; women aOR=2.74, 95%CI=1.77-4.27). The odds of high TC was also higher among married men, and women with higher education or high BMI.ConclusionLow HDL-C prevalence in this relatively young rural population is high whereas high TC prevalence is low. The consequences of dyslipidaemia in African populations remain unclear and prospective follow-up is required.     

Active Trachoma among Children in Mali: Clustering and Environmental Risk Factors

Background

Active trachoma is not uniformly distributed in endemic areas, and local environmental factors influencing its prevalence are not yet adequately understood. Determining whether clustering is a consistent phenomenon may help predict likely modes of transmission and help to determine the appropriate level at which to target control interventions. The aims of this study were, therefore, to disentangle the relative importance of clustering at different levels and to assess the respective role of individual, socio-demographic, and environmental factors on active trachoma prevalence among children in Mali.

Methodology/Principal Findings

We used anonymous data collected during the Mali national trachoma survey (1996–1997) at different levels of the traditional social structure (14,627 children under 10 years of age, 6,251 caretakers, 2,269 households, 203 villages). Besides field-collected data, environmental variables were retrieved later from various databases at the village level. Bayesian hierarchical logistic models were fit to these prevalence and exposure data. Clustering revealed significant results at four hierarchical levels. The higher proportion of the variation in the occurrence of active trachoma was attributable to the village level (36.7%), followed by household (25.3%), and child (24.7%) levels. Beyond some well-established individual risk factors (age between 3 and 5, dirty face, and flies on the face), we showed that caretaker-level (wiping after body washing), household-level (common ownership of radio, and motorbike), and village-level (presence of a women''s association, average monthly maximal temperature and sunshine fraction, average annual mean temperature, presence of rainy days) features were associated with reduced active trachoma prevalence.

Conclusions/Significance

This study clearly indicates the importance of directing control efforts both at children with active trachoma as well as those with close contact, and at communities. The results support facial cleanliness and environmental improvements (the SAFE strategy) as population-health initiatives to combat blinding trachoma.     

Environmental Lead Exposure among Preschool Children in Shanghai,China: Blood Lead Levels and Risk Factors

Objective

To determine blood lead levels and to identify related risk factors among children in Shanghai; to explore the lead change trend of children after industrial transformation and to provide data for policy development to control environmental lead pollution in Shanghai.

Methods

A stratified-clustered-random sampling method was used. A tungsten atomizer absorption spectrophotometer was employed to determine blood lead levels.

Results

The arithmetic mean, geometric mean and median of blood lead levels of 0- to 6-year-old children from Shanghai were 22.49 µg/L, 19.65 µg/L and 19.5 µg/L, including 0.26% (6/2291) with concentrations ≥100 µg/L and 2.7% (61/2291) with concentrations ≥50 µg/L. Boys'' levels (23.57 µg/L) were greater than those of girls (21.2 µg/L). The blood lead levels increased with age. This survey showed that the Chongming district was the highest and Yangpu district was the lowest, this result is completely opposite with the earlier survey in Shanghai. Risk factors for lead contamination included housing environment, parents'' education levels, social status, hobbies, and children''s nutritional status.

Conclusions

The blood lead levels of children in Shanghai were lower than the earlier data of Shanghai and those of published studies in China, but higher than the blood lead levels of developed countries. The blood lead levels of urban districts are higher than the central districts with the industrial transformation. Society and the government should take an active interest in childhood lead poisoning of urban areas.     

Prevalence and Risk Factors for Echinococcal Infection in a Rural Area of Northern Chile: A Household-Based Cross-Sectional Study

Background

Hydatidosis is a zoonotic disease of worldwide distribution caused by Echinococcus granulosus. Our study aimed to determine the prevalence of human and canine echinococcosis as well as the associated risk factors in a rural area of the Limarí province in northern Chile.

Methodology/Principal Findings

A cross-sectional study was conducted between August and November 2009 using a stratified sampling design in each of the five districts of the province. In the selected villages, up to 10 households were sampled. Serum and fecal samples from an adult family member and a dog were collected from each participating household. Risk factors were assessed by standardized questionnaires. Seroprevalence was assessed using a multi-step approach: an ELISA for screening, IFA, IHA and western blot for confirmation of results, respectively. The prevalence of echinococcal infection in dogs was determined by coproantigen genus specific ELISA. Chi-square, Fisher tests and logistic regressions were used to assess risk factors for human seropositivity and dog copropositivity. A seroprevalence of 2.6% (10/403) and coproprevalence of 28% (26/93) was recorded for humans and dogs respectively. Contact with dogs and dog feces were risk factors for human seropositivity while dog copropositivity was associated with home slaughter of livestock (OR = 3.35; CI 90%: 1.16–6.85) and households de-worming dogs (OR = 2.82; CI 90%: 1.33–8.43).

Conclusions/Significance

Echinococcal infection of humans and their dogs is common in Limarí province. Risk factors for human seropositivity were related to contact with domestic dogs and their feces, whereas those for dogs were home slaughter of livestock and the practice of de-worming dogs.     

Clinical Practice Experiences in Diagnosis and Treatment of Traumatic Brain Injury in Children: A Survey among Clinicians at 9 Large Hospitals in China

Proper diagnosis and treatment of traumatic brain injury (TBI) in children is becoming an increasingly problematic issue in China. This study investigated Chinese clinicians to provide information about their knowledge and experiences in diagnosis and treatment of pediatric TBI. We conducted a questionnaire survey among clinicians in the emergency departments and neurosurgery departments at 9 major hospitals in China. The questionnaire included demographic information, and knowledge and experiences regarding the diagnosis and treatment of pediatric TBI. A total of 235 clinicians completed questionnaires. 43.8% of the surveyed clinicians reported children with only scalp hematoma without any other signs and symptoms of concussion as TBI cases. Most clinicians (85.1%) reported no existing uniform diagnostic criteria for children with TBI in China. The majority of clinicians (91.9%) reported that CT scans were performed in all patients with suspected head injury as a routine procedure in their hospitals. Only 20.9% of clinicians believed that radiation from CT scanning may increase cancer risk in children. About 33.6% of the clinicians reported that they ordered CT scans to investigate suspected head injury due to the poor doctor-patient relationship in China, and to protect themselves against any medical lawsuits in the future. About 80% of the clinicians reported that there are no existing pediatric TBI treatment guidelines in China. Instead a senior doctor’s advice is the most reported guidelines regarding treating pediatric TBI (66.0%). All of the surveyed clinicians reported that the lack of diagnosis and/or treatment standard is the biggest problem in effectively diagnosing and treating pediatric TBI in China. Developing guidelines for the diagnosis and treatment of children with TBI is a high priority in China. The extremely high usage of CT for pediatric TBI in China suggests that it is important to establish evidence-based clinical decision rules to help Chinese clinicians make diagnostic and therapeutic decisions during their practice in order to identify children unlikely to have a clinically-important TBI who can be safely discharged without a CT scan.     

Prevalence and Risk Factors of Restless Legs Syndrome among Chinese Adults in a Rural Community of Shanghai in China

Aims

The primary objective of this study was to investigate the prevalence and risk factors of restless legs syndrome (RLS) in an adult Chinese population living in a rural community. We also aimed to determine the predictive diagnostic value of the 4-item screening questionnaire for RLS in this population.

Methods

This study was designed as a 2-phase survey. In phase 1 we performed a face-to-face interview of eligible individuals living in a rural community in Shanghai using a 4-item screening questionnaire. In phase 2, sleep specialists performed a phone interview of the individuals who screened positive to diagnosis RLS.

Results

Forty-one RLS cases were confirmed among 2941 eligible individuals 18 years of age or older in the study community. The prevalence of RLS was 1.4% (95% confidence interval (CI) =1.0-1.9%), with a significantly higher rate observed in females (1.9% [95%CI =1.3-2.7%]) than that in males (0.9% [95%CI =0.5-1.5%], p=0.019). The prevalence rate increased significantly with age, from 0.2% (95% CI =0.08-0.6%) in those 18-39 years old to 4.1% (95% CI =2.1-7.9%) in those ≥70 years old (p<0.001). The multivariate logistic regression analysis indicated that gastritis, anemia and hypertension were risk factors for RLS. The sensitivity and specificity of the 4-item screening questionnaire used in this study were 63.4% and 97.5%, respectively.

Conclusion

RLS prevalence is relatively low among Chinese adults living in rural Shanghai. Furthermore, population-based studies with a larger sample size and a longitudinal follow-up may help to determine the risk factors of RLS and potential interventions for RLS.     

Pulmonary Tuberculosis Incidence and Risk Factors in Rural Areas of China: A Cohort Study

The incidence of tuberculosis (TB) and its risk factors in China remains unclear. This study examined TB incidence and relative risk factors in rural areas of China. Participants (n = 177,529) were recruited in Xiangtan County (in the central area of China) and in Danyang County (in the eastern area of China) in 2009 and a followed-up study was conducted for one year. The incidence density of pulmonary TB and smear-positive TB were 91.6 (95% CI: 78.7, 106.0) per 100,000 person-year and 36.7 (95% CI: 33.1, 52.4) per 100,000 person-year respectively in Xiangtan, and 47.3 (95% CI: 38.2, 57.5) per 100,000 person-year and 22.7 (95% CI: 16.5, 30.8) per 100,000 person-year in Danyang. The medical history of TB was associated with TB, with the relative risk (RR) of 7.00 (95% CI: 2.76, 17.18) in Xiangtan and that of 31.08 (95% CI: 13.22, 73.10) in Danyang. The association between TB and per capita living space over median was found in Xiangtan, with the RR of 1.86 (95% CI: 1.15, 3.01). No association was found between TB and the insurance status, the contact history with TB, the history of diabetes, smoking, or per capita annual income. The host genetic susceptibility, and social factors such as education and income could be considered in future studies.     

Risk Factors for Mercury Exposure of Children in a Rural Mining Town in Northern Chile

Objective

Traditional gold mining is associated with mercury exposure. Especially vulnerable to its neurotoxic effects is the developing nervous system of a child. We aimed to investigate risk factors of mercury exposure among children in a rural mining town in Chile.

Methods

Using a validated questionnaire distributed to the parents of the children, a priori mercury risk factors, potential exposure pathways and demographics of the children were obtained. Mercury levels were measured through analyzing fingernail samples. Logistic regression modeling the effect of risk factors on mercury levels above the 75^th percentile were made, adjusted for potential confounders.

Results

The 288 children had a mean age of 9.6 years (SD = 1.9). The mean mercury level in the study population was 0.13 µg/g (SD 0.11, median 0.10, range 0.001–0.86 µg/g). The strongest risk factor for children’s odds of high mercury levels (>75^th percentile, 0.165 µg/g) was to play inside a house where a family member worked with mercury (OR adjusted 3.49 95% CI 1.23–9.89). Additionally, children whose parents worked in industrial gold mining had higher odds of high mercury levels than children whose parents worked in industrial copper mining or outside mining activities.

Conclusion

Mercury exposure through small-scale gold mining might affect children in their home environments. These results may further help to convince the local population of banning mercury burning inside the households.     

Incidence,Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

Background

Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients.

Methodology

A total 667 dengue patients (2008–2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods.

Results

There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64–17.59), P<0.001], rhabdomyolysis [OR (95% CI): 7.9 (3.04–20.49)], multiple organ dysfunction [OR (95% CI): 34.6 (14.14–84.73), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12–19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12–19.86), P = 0.033] and use of nephrotoxic drugs [OR (95% CI): 2.9 (1.12–19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3 days) was also observed among AKI patients (OR = 1.3, P = 0.044). Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI.

Conclusions

The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians’ alertness to this highly morbid and potentially fatal complication for optimal prevention and management.     

Blood Lead Levels and Associated Factors among Children in Guiyu of China: A Population-Based Study

Objectives

Children''s health problems caused by the electronic waste (e-waste) lead exposure in China remains. To assess children''s blood lead levels (BLLs) in Guiyu of China and investigate risk factors of children''s elevated BLLs in Guiyu.

Material and Methods

842 children under 11 years of age from Guiyu and Haojiang were enrolled in this population-based study during 2011–2013. Participants completed a lifestyle and residential environment questionnaire and their physical growth indices were measured, and blood samples taken. Blood samples were tested to assess BLLs. Children''s BLLs between the two groups were compared and factors associated with elevated BLLs among Guiyu children were analyzed by group Lasso logistic regression model.

Results

Children living in Guiyu had significant higher BLLs (7.06 µg/dL) than the quantity (5.89 µg/dL) of Haojiang children (P<0.05). Subgroup analyses of BLLs exceeding 10 µg/dL showed the proportion (24.80%) of high-level BLLs for Guiyu children was greater than that (12.84%) in Haojiang (P<0.05). Boys had greater BLLs than girls, irrespectively of areas (P<0.05). The number of e-waste piles or recycling workshops around the house (odds ratio, 2.28; 95% confidence interval [CI], 1.37 to 3.87) significantly contributed to the elevated BLLs of children in Guiyu, and girls had less risk (odds ratio, 0.51; 95% CI, 0.31 to 0.83) of e-waste lead exposure than boys.

Conclusions

This analysis reinforces the importance of shifting e-waste recycling piles or workshops to non-populated areas as part of a comprehensive response to e-waste lead exposure control in Guiyu. To correct the problem of lead poisoning in children in Guiyu should be a long-term mission.     

Magnitude of Cardiovascular Risk Factors in Rural and Urban Areas in Benin: Findings from a Nationwide Steps Survey

ObjectiveTo describe and compare the prevalences of CVRF in urban and rural populations of Benin.MethodsSubjects were drawn from participants in the Benin Steps survey, a nationwide cross-sectional study conducted in 2008 using the World Health Organisation (WHO) stepwise approach to surveillance of chronic disease risk factors. Subjects aged above 24 and below 65 years were recruited using a five-stage random sampling process within households. Sociodemographic data, behavioral data along with medical history of high blood pressure and diabetes mellitus were collected in Step 1. Anthropometric parameters and blood pressure were measured in Step 2. Blood glucose and cholesterol levels were measured in Step 3. CVRF were defined according to WHO criteria. The prevalences of CVRF were assessed and the relationships between each CVRF and the area of residence (urban or rural), were evaluated using multivariable logistic regression models.ResultsOf the 6762 subjects included in the study, 2271 were from urban areas and 4491 were from rural areas. High blood pressure was more prevalent in urban than in rural areas, 29.9% (95% confidence intervals (95% CI): 27.4, 32.5) and 27.5% (95% CI: 25.6, 29.5) respectively, p = 0.001 (p-value after adjustment for age and gender). Obesity was more prevalent in urban than in rural areas, 16.4% (95% CI: 14.4, 18.4) and 5.9% (95% CI: 5.1, 6.7), p<0.001. Diabetes was more prevalent in urban than in rural areas, 3.3% (95% CI: 2.1, 4.5) and 1.8% (95% CI: 1.2, 2.4), p = 0.004. Conversely, daily tobacco smoking was more prevalent in rural than in urban areas, 9.3% (95% CI: 8.1, 10.4) and 4.3% (95% CI: 3.1, 5.6), p<0.001. No differences in raised blood cholesterol were noted between the two groups.ConclusionAccording to our data, CVRF are prevalent among adults in Benin, and variations between rural and urban populations are significant. It may be useful to take account of the heterogeneity in the prevalence of CVRF when planning and implementing preventive interventions.     

Risk Factors of Internet Addiction among Internet Users: An Online Questionnaire Survey

Backgrounds

Internet addiction (IA) has become a major public health issue worldwide and is closely linked to psychiatric disorders and suicide. The present study aimed to investigate the prevalence of IA and its associated psychosocial and psychopathological determinants among internet users across different age groups.

Methods

The study was a cross-sectional survey initiated by the Taiwan Suicide Prevention Center. The participants were recruited from the general public who responded to the online questionnaire. They completed a series of self-reported measures, including Chen Internet Addiction Scale-revised (CIAS-R), Five-item Brief Symptom Rating Scale (BSRS-5), Maudsley Personality Inventory (MPI), and questions about suicide and internet use habits.

Results

We enrolled 1100 respondents with a preponderance of female subjects (85.8%). Based on an optimal cutoff for CIAS-R (67/68), the prevalence rate of IA was 10.6%. People with higher scores of CIAS-R were characterized as: male, single, students, high neuroticism, life impairment due to internet use, time for internet use, online gaming, presence of psychiatric morbidity, recent suicide ideation and past suicide attempts. Multiple regression on IA showed that age, gender, neuroticism, life impairment, internet use time, and BSRS-5 score accounted for 31% of variance for CIAS-R score. Further, logistic regression showed that neuroticism, life impairment and internet use time were three main predictors for IA. Compared to those without IA, the internet addicts had higher rates of psychiatric morbidity (65.0%), suicide ideation in a week (47.0%), lifetime suicide attempts (23.1%), and suicide attempt in a year (5.1%).

Conclusion

Neurotic personality traits, psychopathology, time for internet use and its subsequent life impairment were important predictors for IA. Individuals with IA may have higher rates of psychiatric morbidity and suicide risks. The findings provide important information for further investigation and prevention of IA.     

我国儿童烧伤危险因素的文献回顾性分析

在儿童意外伤害中,烧伤因其伴随明显的损伤后瘢痕形成及高致残率一直备受关注。儿童烧伤不仅使患儿的身体受到损伤,且给家庭、社会带来沉重的负担,其造成的心理阴影可能伴随患儿终生。为寻找我国儿童烧伤的危险因素并有针对性的制定预防措施,作者对2000～2010年间我国不同地区、不同医疗单位发表的有关儿童烧伤流行病学特征及危险因素分析的文献进行了回顾性分析,结果发现我国儿童烧伤的危险因素不仅存在着一些共性,而且不同地区之间也互有差异。     

Prevalence and Clustering of Cardiovascular Disease Risk Factors among Tibetan Adults in China: A Population-Based Study

Objectives

The prevalence of cardiovascular disease risk factors has increased worldwide. However, the prevalence and clustering of cardiovascular disease risk factors among Tibetans is currently unknown. We aimed to explore the prevalence and clustering of cardiovascular disease risk factors among Tibetan adults in China.

Methods

In 2011, 1659 Tibetan adults (aged ≥18 years) from Changdu, China were recruited to this cross-section study. The questionnaire, physical examinations and laboratory testing were completed and the prevalence of cardiovascular disease risk factors, including hypertension, diabetes, overweight/obesity, dyslipidemia, and current smoking, were counted. The association between the clustering of cardiovascular disease risk factors and demographic characteristics, and geographic altitude were assessed.

Results

The age-standardized prevalence of hypertension, diabetes, overweight or obesity, dyslipidemia, and current smoking were 62.4%, 6.4%, 34.3%, 42.7%, and 6.1%, respectively, and these risk factors were associated with age, gender, education level, yearly family income, altitude, occupation, and butter tea consumption (P < 0.05). Overall, the age-adjusted prevalence of clustering of ≥1, ≥2, and ≥3 cardiovascular disease risk factors were 79.4%, 47.1%, and 20.9%, respectively. There appeared higher clustering of ≥2 and ≥3 cardiovascular disease risk factors among Tibetans with higher education level and family income yearly, and those living at an altitude < 3500 m and in a township.

Conclusions

The prevalence of cardiovascular disease risk factors, especially hypertension, was high in Tibetans. Moreover, there was an increased clustering of cardiovascular disease risk factors among those with higher socioeconomic status, lamas and those living at an altitude < 3500 m. These findings suggest that without the immediate implementation of an efficient policy to control these risk factors, cardiovascular disease will eventually become a major disease burden among Tibetans.     

Risk Factors Associated with Recurrent Diarrheal Illnesses among Children in Kabul,Afghanistan: A Prospective Cohort Study

IntroductionChildhood diarrheal illnesses are a major public health problem. In low-income settings data on disease burden and factors associated with diarrheal illnesses are poorly defined, precluding effective prevention programs. This study explores factors associated with recurrent diarrheal illnesses among children in Kabul, Afghanistan.MethodsA cohort of 1–11 month old infants was followed for 18 months from 2007–2009. Data on diarrheal episodes were gathered through active and passive surveillance. Information on child health, socioeconomics, water and sanitation, and hygiene behaviors was collected. Factors associated with recurrent diarrheal illnesses were analyzed using random effects recurrent events regression models.Results3,045 children were enrolled and 2,511 (82%) completed 18-month follow-up. There were 14,998 episodes of diarrheal disease over 4,200 child-years (3.51 episodes/child-year, 95%CI 3.40–3.62). Risk of diarrheal illness during the winter season was 63% lower than the summer season (HR = 0.37, 95%CI 0.35–0.39, P<0.001). Soap for hand washing was available in 72% of households and 11.9% had toilets with septic/canalization. Half of all mothers reported using soap for hand washing. In multivariate analysis diarrheal illness was lower among children born to mothers with post-primary education (aHR = 0.79, 95%CI 0.69–0.91, p = 0.001), from households where maternal hand washing with soap was reported (aHR = 0.83, 95%CI 0.74–0.92, p<0.001) and with improved sanitation facilities (aHR = 0.76, 95%CI 0.63–0.93, p = 0.006). Malnourished children from impoverished households had significantly increased risks for recurrent disease [(aHR = 1.15, 95%CI 1.03–1.29, p = 0.016) and (aHR = 1.20, 95%CI 1.05–1.37, p = 0.006) respectively].ConclusionsMaternal hand washing and improved sanitation facilities were protective, and represent important prevention points among public health endeavors. The discrepancy between soap availability and utilization suggests barriers to access and knowledge, and programs simultaneously addressing these aspects would likely be beneficial. Enhanced maternal education and economic status were protective in this population and these findings support multi-sector interventions to combat illness.

Trial Registration

www.ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00548379","term_id":"NCT00548379"}}NCT00548379 https://www.clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00548379","term_id":"NCT00548379"}}NCT00548379