Anna Simon

Multisite Study of Cryptosporidiosis in Children with Diarrhea in India

ABSTRACT Cryptosporidium spp., a common cause of diarrhea in children, were investigated in the first multisite study in India. Diarrheal stools from hospitalized children aged <5 years from Delhi, Trichy, and Vellore were analyzed by microscopy, PCR-restriction fragment length polymorphism (RFLP), and/or sequencing at the small-subunit (SSU) rRNA and Cpgp40/15 loci for species determination and subgenotyping, respectively. Seventy of 2,579 (2.7%) children, 75% of whom were <2 years old, had cryptosporidial diarrhea as determined by microscopy. Genotyping and subgenotyping showed that Cryptosporidiumhominis was the most commonly identified species (59/67 children), and subgenotypes Ie, Ia, Ib, and Id were common in all centers. A novel C. parvum subgenotype, IIn, was identified in Vellore. Meteorological analysis revealed a higher rate of cryptosporidial positivity during hotter and drier weather in Delhi.

Diversity of circulating rotavirus strains in children hospitalized with diarrhea in India, 2005-2009.

BACKGROUND India accounts for 22% of the 453,000 global rotavirus deaths among children <5 years annually. The Indian Rotavirus Strain Surveillance Network provides clinicians and public health partners with valuable rotavirus disease surveillance data. Our analysis offers policy-makers an update on rotavirus disease burden with emphasis on regional shifts in rotavirus strain epidemiology in India. METHODS Children <5 years requiring hospitalization for acute gastroenteritis were selected from 10 representative hospitals in 7 cities throughout India between November 2005 through June 2009. We used a modified World Health Organization protocol for rotavirus surveillance; stool specimens were collected and tested for rotavirus using enzyme immunoassay and reverse-transcription polymerase chain reaction. RESULTS A total of 7285 stool specimens collected were tested for rotavirus, among which 2899 (40%) were positive for rotavirus. Among the 2899 rotavirus detections, a G-type could not be determined for 662 (23%) and more than one G type was detected in 240 (8%). Of 1997 (69%) patients with only one G-type, the common types were G1 (25%), G2 (21%), G9 (13%), and G12 (10%). The proportion of rotavirus infections attributed to G12 infections rose from 8% to 39% in the Northern region and from 8% to 24% in the Western region. CONCLUSIONS This study highlights the large, ongoing burden of rotavirus disease in India, as well as interesting regional shifts in rotavirus strain epidemiology, including an increasing detection of G12 rotavirus strains in some regions. While broad heterotypic protection from rotavirus vaccination is expected based on pre- and post-licensure data from other settings, effectiveness assessments and rotavirus strain monitoring after vaccine introduction will be important.

Food marketing towards children: brand logo recognition, food-related behavior and BMI among 3-13-year-olds in a south Indian town.

Objectives To assess exposure to marketing of unhealthy food products and its relation to food related behavior and BMI in children aged 3–13, from different socioeconomic backgrounds in a south Indian town. Methods Child-parent pairs (n = 306) were recruited at pediatric clinics. Exposure to food marketing was assessed by a digital logo recognition test. Children matched 18 logos of unhealthy food (high in fat/sugar/salt) featured in promotion material from the food industry to pictures of corresponding products. Childrens nutritional knowledge, food preferences, purchase requests, eating behavior and socioeconomic characteristics were assessed by a digital game and parental questionnaires. Anthropometric measurements were recorded. Results Recognition rates for the brand logos ranged from 30% to 80%. Logo recognition ability increased with age (p<0.001) and socioeconomic level (p<0.001 comparing children in the highest and lowest of three socioeconomic groups). Adjusted for gender, age and socioeconomic group, logo recognition was associated with higher BMI (p = 0.022) and nutritional knowledge (p<0.001) but not to unhealthy food preferences or purchase requests. Conclusions Children from higher socioeconomic groups in the region had higher brand logo recognition ability and are possibly exposed to more food marketing. The study did not lend support to a link between exposure to marketing and poor eating behavior, distorted nutritional knowledge or increased purchase requests. The correlation between logo recognition and BMI warrants further investigation on food marketing towards children and its potential role in the increasing burden of non-communicable diseases in this part of India.

Multi-center surveillance of rotavirus diarrhea in hospitalized children <5 years of age in India, 2009–2012

Diarrheal disease due to Group A rotaviruses continues to be an important cause of morbidity in the developing world and India contributes significantly to the disease burden. Surveillance carried out between July 2009 and June 2012 at two medical centers in south India and one center in north India estimated 39% of all diarrheal admissions to be due to rotavirus. The most prevalent genotype isolated was G1P[8](33%) followed by G2P[4](17%). G9P[4] has also emerged as a significant cause of rotavirus diarrhea. No seasonal variation was noticed from the centers in south India, whereas we observed increased rotavirus diarrhea in the center in north India during March and April.

Randomized, Open-Label Study of the Impact of Age on Booster Responses to the 10-Valent Pneumococcal Nontypeable Haemophilus influenzae Protein D Conjugate Vaccine in Children in India

ABSTRACT In this phase III, open-label, multicenter, and descriptive study in India, children primed with 3 doses (at ages 6, 10, and 14 weeks) of the 10-valent pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) were randomized (1:1) to receive a booster dose at 9 to 12 (early booster) or 15 to 18 months old (late booster) in order to evaluate impact of age at booster. We also evaluated a 2-dose catch-up vaccination plus an experimental booster dose in unprimed children age 12 to 18 months. The early booster, late booster, and catch-up vaccinations were administered to 74, 95, and 87 children, respectively; 66, 71, and 81 children, respectively, were included in the immunogenicity according-to-protocol cohort. One month postbooster, for each PHiD-CV serotype, ≥95.2% (early booster) and ≥93.8% (late booster) of the children had antibody concentrations of ≥0.2 μg/ml; ≥96.7% and ≥93.0%, respectively, had opsonophagocytic activity (OPA) titers of ≥8. The postbooster antibody geometric mean concentrations (GMCs) were in similar ranges for early and late boosters; the OPA titers appeared to be lower for most PHiD-CV serotypes (except 6B and 19F) after the early booster. After dose 2 and postbooster, for each PHiD-CV serotype, ≥88.6% and ≥96.3%, respectively, of the catch-up immunogenicity according-to-protocol cohort had antibody concentrations of ≥0.2 μg/ml; ≥71.4% and ≥90.6%, respectively, had OPA titers of ≥8. At least 1 serious adverse event was reported by 2 children in the early booster (skin infection and gastroenteritis) and 1 child in the catch-up group (febrile convulsion and urinary tract infection); all were resolved, and none were considered by the investigators to be vaccine related. PHiD-CV induced robust immune responses regardless of age at booster. Booster vaccination following 2 catch-up doses induced robust immune responses indicative of effective priming and immunological memory. (These studies have been registered at www.clinicaltrials.gov under registration no. NCT01030822 and NCT00814710; a protocol summary is available at www.gsk-clinicalstudyregister.com [study ID 112909]).

Vitamin D deficiency rickets with Lamellar ichthyosis

Examination revealed trauma-induced phthisis bulbi of the right eye and recurrent retinal detachment (rhegmatogenous) of the left eye with aphakia. There was also evidence of coarse chorioretinal atrophy on fundus examination of left eye suggestive of myopic disease. There was no positive family history or evidence of dural ectasia on MRI examination of the spines. Based on these, a diagnosis of Marfans syndrome was made in our patient.[4] Our patient satisfied the diagnosis of Marfans syndrome proposed by Rimoin et al in the absence of a positive family history by the presence of two major criteria (aortic dissection and aortic root dilatation) and the presence of more than two minor criteria (myopia, retinal detachment, mitral valve prolapse, skeletal deformities).[5]

Primary pigmented nodular adrenocortical disease

Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of ACTH-independent Cushings syndrome and has characteristic gross and microscopic pathologic findings. We report a case of PPNAD in a 15-year-old boy, which was not associated with Carneys complex. Bilateral adrenalectomy is the treatment of choice.

Nitric oxide production in acute gastroenteritis in Indian children

This study compared nitric oxide (NO) levels in 110 children with, and 110 children without, infectious gastroenteritis. Post-infection intestinal function was assessed in a subset. At least one pathogen was identified in 47.2% of cases. The most common diarrhoeal pathogens were rotavirus (22.7%) and norovirus genogroup II (11.8%). The levels of NO measured by median urinary nitrite:creatinine ratio were significantly higher in children with diarrhoea [23.6; interquartile range (IQR) 12.3-46.7] than without diarrhoea (7.8; IQR 4.1-13.2), P<0.001. The ratio was not significantly different between diarrhoeal cases with and without pathogens (P=0.148). Six of twelve children tested had intestinal dysfunction.

Pierson Syndrome - A Rare Cause of Congenital Nephrotic Syndrome

To the Editor: Pierson syndrome is a rare genetic cause of congenital nephrotic syndrome (CNS) with renal insufficiency and ocular anomaly, typically microcoria. We are reporting a boy, who presented on the 30th postnatal day with progressive abdominal distension and swelling of lower limbs and genitalia. He was born at term with birth weight of 2 kg. Family history was negative for any heritable renal or ophthalmic disorders. He had anasarca, ascites and bilateral microcoria with hypopigmented iris (Fig. 1). Other systems were normal. Investigations showed 4+proteinuria on dipstick, severe hypoalbuminemia (0.8 g %), renal insufficiency [Creatinine 0.9 mg %, Creatinine clearance 17.6 ml/min/1.73sq.m BSA]; hyponatremia (110 meq/L), hyperphosphatemia (7.4 mg %), acidosis (HCO3:7 meq/L), hypercholesterolemia (188 mg%) and very high urine protein/creatinine ratio (108.5), confirmatory of CNS. Ultrasonogram showed normal kidneys. Screening for intrauterine infections was negative. In view of CNS with ocular anomalies, Pierson syndrome was considered. Ophthalmic findings were papillary constriction persisting despite using mydriatics, hypochromic iris and mild keratoconus. The baby was treated for the clinical conditions of anasarca, hyponatremia and acidosis. We considered the feasibility of renal biopsy and genetic analysis but parents decided against further investigations or treatment and got discharged at request. In 1963, Pierson reported two siblings with congenital nephrotic syndrome, microcoria and renal failure rapidly progressing to death [1]. The most characteristic ocular anomaly was microcoria, additional abnormalities include posterior embryotoxon, megalocornea, iris hypoplasia, cataract, abnormal lens shape, posterior lenticonus, persistent fetal vascula-

Norovirus Genogroup II Gastroenteritis in Hospitalized Children in South India

The distribution of norovirus (NoV) genogroup II in children < 5 years of age admitted to a south Indian hospital with diarrhea was investigated. Viral RNA extracted from 282 stool samples were screened for NoV GII and positive amplicons sequenced. Twenty-eight (9.9%) had NoV GII infection with a median age of 6 months, with more severe episodes of diarrhea among infected (median Vesikari score 13, interquartile range [IQR] 10-15) than children without infection (median score 10, IQR 8-13, P = 0.002). The study documents NoV GII infections as an important cause of gastroenteritis and the genetic diversity of circulating strains.