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Objective To examine racial and socioeconomic differences in parental beliefs about the appropriate age at which to initiate toilet training. Study design A cross-sectional survey of 779 parents visiting child health providers in 3 clinical sites in Washington, DC and the surrounding metropolitan area completed a self-report survey. The main outcome variable was parental beliefs about the appropriate age at which to initiate toilet training. Using multiple linear regression, differences in beliefs were assessed in relation to race, family income, parental education, parental age, and age of the oldest and youngest children. Results Among respondents, parents felt that the average age at which toilet training should be initiated was 20.6 months (±7.6 months), with a range of 6 to 48 months. Caucasian parents believed that toilet training should be initiated at a significantly later age (25.4 months) compared with both African-American parents (18.2 months) and parents of other races (19.4 months). In the multiple regression model, factors predicting belief in when to initiate toilet training were Caucasian race and higher income. Conclusions Race and income were independent predictors of belief in age at which to initiate toilet training. More research is needed to determine what factors contribute to toilet training practices in diverse populations.

This paper discusses considerations in public health for the introduction of tetravalent rhesus rotavirus-based reassortant vaccine (RRV-TV) for infants. RRV-TV contains a mixture of G1, G2, and G4 reassortants with a parent strain of MMU 18006. Field trials were performed to evaluate the protective efficacy of RRV-TV in infants and to determine the efficacy of RRV-TV higher-dose regimen. The use of RRV-TV in infant immunization brings about the following relevant issues: 1) availability of alternative or complementary non-vaccine interventions; 2) burden of disease; 3) epidemiologic features of rotavirus disease; 4) protective characteristics of the vaccine in efficacy trials; 5) clinical effectiveness of the vaccine; and 6) balance between costs and benefits of vaccination. Moreover, due to its high cost, RRV-TV would not be a cost-saving public health tool in developing countries unless it is made affordable. An effective vaccine against rotavirus is needed due to the following factors: 1) immense burden of rotavirus; 2) persistence of disease burden despite the promotion of rehydration therapy for acute diarrheas in childhood; and 3) lack of effectiveness of nonvaccination approaches.

The authors estimated the incidence rates of cholera and death between 1985 and 1988 for 32,642 age- and sex-eligible persons who did not participate in a randomized, placebo-controlled field trial of killed oral cholera vaccines in rural Bangladesh. As compared with 20,744 placebo recipients, the relative risk of cholera for all nonparticipants, adjusted for potentially confounding demographic variables, was 1.20 (95% confidence interval (CI) 1.03-1.41); this adjusted relative risk reflected elevated adjusted relative risks in nonparticipants who were medically ineligible (RR = 1.65; 95% CI 1.22-2.22) or refused to participate (RR = 1.19; 95% CI 1.01-1.41), but not in persons absent at the time of vaccination (RR = 1.00; 95% CI 0.78-1.28). The adjusted relative risk of death was also elevated in nonparticipants as compared with placebo recipients (RR = 1.28; 95% CI 1.10-1.48), with the same pattern of adjusted relative risks for different categories of nonparticipants: for ineligible subjects, 2.64 (95% CI 2.12-3.29); for refusers, 1.20 (95% CI 1.02-1.41); and for absentees, 0.95 (95% CI 0.75-1.22). The authors concluded that nonparticipation was associated with clinically cogent adverse health outcomes, but that the magnitude of these associations varied according to the reason for nonparticipation. These findings underscore the caution required in assessing vaccine efficacy with controls who are not vaccinated because of choices made by patients or vaccinators.

Background. Initiation of breastfeeding shortly after delivery may enhance breastfeeding's protective effect against diarrhea because of the protective properties of human colostrum contained in early breast milk. Objective. To evaluate whether initiation of breastfeeding within the first 3 days of life, when breast milk contains colostrum, was associated with a lower rate of diarrhea in rural Egyptian infants during the first 6 months of life. Methods. Infants initially breastfed (n = 198) were monitored prospectively with twice-weekly home visits to ascertain dietary practices and diarrheal illnesses. Results. The burden of diarrhea during the first 6 months of life in the cohort was high: seven episodes per child-year of follow-up. Only 151 (76%) infants initiated breastfeeding during the first 3 days of life (“early initiation”). Infants in whom breastfeeding was initiated early had a 26% (95% CI: 2%,44%) lower rate of diarrhea than those initiated late. The protective association between early initiation and diarrhea was independent of the pattern of postinitiation dietary practices and was evident throughout the first 6 months of life. Conclusions. Early initiation of breastfeeding was associated with a marked reduction of the rate of diarrhea throughout the first 6 months of life, possibly because of the salutary effects of human colostrum. These data highlight the need for interventions to encourage early initiation of breastfeeding in less developed settings.

To ascertain whether measles vaccination was associated with reduced mortality rates in rural Bangladeshi children, the authors conducted a case-control study in four contiguous areas, two of which had participated in an intensive measles vaccination program which began in the spring of 1982. Cases were 536 children who had died in the four-area region at the age of 10-60 months between April 1982 and December 1984. Two age- and sex-matched controls were selected from the four-area region for each case; each control had survived at least through the date of death of the matched case. Measles vaccination was associated with a 36% (95% confidence interval 21%-48%) proportionate reduction in the overall rate of death and a 57% (95% confidence interval 43%-67%) reduction in the rate of deaths directly attributed to measles or ascribed to diarrhea, respiratory illness, or malnutrition. The association of measles vaccination and reduced mortality remained unchanged after the authors restricted controls to children who had survived at least one year after the deaths of their matched cases. Moreover, children vaccinated in 1982 exhibited a sustained reduction in the rate of death in 1983 and 1984. The authors concluded that measles vaccination was associated with a pronounced and sustained reduction in the rate of death among children in this study.

We investigated whether alternative clinical and microbiological criteria for outcome events affected estimates of vaccine efficacy in a randomized, double-blind field trial of B subunit-killed whole cell (BS-WC) and killed whole cell-only (WC) oral cholera vaccines among 62,285 rural Bangladeshi participants. At one year of follow-up estimates of vaccine protective efficacy (PE = 60%, P less than 0.0001 for BS-WC; PE = 54%, P less than 0.0001 for WC) against all treated diarrhoeal episodes associated with V. cholerae 01 were similar to estimates of efficacy against only those episodes which were clinically typical and unassociated with additional enteric pathogens (PE = 62%, P less than 0.0001 for BS-WC; PE = 52%, P less than 0.0001 for WC). In contrast, estimates of vaccine cross-protection against episodes associated with each of several agents antigenically related to V. cholerae 01 (LT-ETEC, non-cholera Vibrio sp, Aeromonas sp) were substantially reduced when mixed infections with V. cholerae 01 were excluded. We conclude that restrictive criteria intended to improve the specificity of the definition of cholera did not increase the detectability of vaccine efficacy against V. cholerae 01, but that exclusion of mixed infections with V. cholerae 01 was necessary to avoid false-positive conclusions about vaccine cross-protection against other potential target pathogens.