Page 14 - An epidemiological perspective on gastroenteritis in child day care centers • Assessment of impact and risk

Chapter 1
major clinical manifestations: gastroenteritis, as the microorganisms (or enteropathogens) underlying gastroenteritis are transmitted via the faecal-oral route. Strategies to prevent faecal contamination of the DCC environment may therefore, in principle, help to reduce the gastroenteritisburden.Forrespiratoryinfections, modifiable characteristics with intervention potentialaremuchmoredifficulttoidentify.7,8 Similarly, although there are two major types of formal out-of-home care facilities related to the Netherlands - the DCC (size: 5 up to a few hundred children) and the day care home9 (size: 1 to 6 children) -, this thesis focuses mainly on the DCC. We will provide answers to two core questions of DCC-related gastroenteritis: (1) 'what is the impact of gastroenteritis related to child day care centers' and (2) which risk factors are associated with gastroenteritis in child day care centers?'
The large remainder of this introductory chapter is dedicated to discussing the gastroenteritis syndrome, the characteristics that predispose a DCCtowardstransmissionofenteropathogens that cause gastroenteritis, and the potential and feasibility of day care control strategies that may reduce enteropathogen transmission. As these aspects are considered, several questions arise for which the Netherlands currently lacks evidence-based answers. These questions are operationalized in seven research questions that this thesis will attempt to answer using a variety of data sources.
Gastroenteritis and the day care center environment
Gastroenteritis; increased risk in child day care centers
In this thesis, we refer to gastroenteritis as an inflammation of the gastrointestinal tract. Gastroenteritis has infectious and non-infectious causes. It is defined by its clinical picture, which may include a myriad of symptoms including vomiting, diarrhoea, nausea, fever and abdominal pain. Gastroenteritis causes mortality, accounting for 4% (or 2.2 million) of annual deaths worldwide.10 Most deaths occur in developing countries among children under five years of age. In developed countries such as the Netherlands, child mortality rates are low, primarily due to improved hygiene and sanitation standards, improved nutritional status and timely treatment when needed. In the Netherlands, gastroenteritis episodes are mainly mild and self-limiting, although episodes with a high burden do occur.11 However, given the high incidence of generally mild gastroenteritis episodes, the overall morbidity remains high.11-13 This holds especially true for children attending DCCs that, in the Netherlands, provide government-regulated, paid, non- custodial care for five and up to a few hundred children aged 0-4 years. Several studies have indicated that children attending DCCs are at increased risk of developing gastroenteritis compared to children cared for at home.14-16 The caring for and treatment of children with gastroenteritis is likely to result in substantial
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