world by as much as 30%. alcohol-based gels may also be effective. food or drink that is thought to be contaminated should be avoided. breastfeeding is important, especially in places with poor hygiene, as is improvement of hygiene generally. breast milk reduces both the frequency of infections and their duration. vaccination due to both its effectiveness and safety, in 2009 the world health organization recommended that the rotavirus vaccine be offered to all children globally. two commercial rotavirus vaccines exist and several more are in development. in africa and asia these vaccines reduced severe disease among infants and countries that have put in place national immunization programs have seen a decline in the rates and severity of disease. this vaccine may also prevent illness in non-vaccinated children by reducing the number of circulating infections. since 2000, the implementation of a rotavirus vaccination program in the united states has substantially decreased the number of cases of diarrhea by as much as 80 percent. the first dose of vaccine should be given to infants between 6 and 15 weeks of age. the oral cholera vaccine has been found to be 50–60% effective over two years. there are a number of vaccines against gastroenteritis in development. for example, vaccines against shigella and enterotoxigenic escherichia coli (etec), which are two of the leading bacterial causes of gastroenteritis worldwide. management gastroenteritis is usually an acute and self-limiting disease that does not require medication. the preferred treatment in those with mild to moderate dehydration is oral rehydration therapy (ort). for children at risk of dehydration from vomiting, taking a single dose of the anti vomiting medication metoclopramide or ondansetron, may be helpful, and butylscopolamine is useful in treating abdominal pain. rehydration the primary treatment of gastroenteritis in both children and adults is rehydration. this is preferably achieved by drinking rehydration solution, although intravenous delivery may be required if there is a decreased level of consciousness or if dehydration is severe. drinking replacement therapy products made with complex carbohydrates (i.e. those made from wheat or rice) may be superior to those based on simple sugars. drinks especially high in simple sugars, such as soft drinks and fruit juices, are not recommended in children under five years of age as they may increase diarrhea. plain water may be used if more specific ort preparations are unavailable or the person is not willing to drink them. a nasogastric tube can be used in young children to administer fluids if warranted. in those who require intravenous fluids, one to four hours' worth is often sufficient. dietary it is recommended that breast-fed infants continue to be nursed in the usual fashion, and that formula-fed infants continue their formula immediately after rehydration with ort. lactose-free or lactose-reduced formulas usually are not necessary. children should continue their usual diet during episodes of diarrhea with the exception that foods high in simple sugars should be avoided. the brat diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding. a cochrane review from 2020 concludes that probiotics make little or no difference to people who have diarrhea lasting 2 days or longer and that there is no proof that they reduce its duration. they may be useful in preventing and treating antibiotic associated diarrhea. fermented milk products (such as yogurt) are similarly beneficial. zinc supplementation appears to be effective in both treating and preventing diarrhea among children in the developing world. antiemetics antiemetic medications may be helpful for treating vomiting in children. ondansetron has some utility, with a single dose being associated with less need for intravenous fluids, fewer hospitalizations, and decreased vomiting. metoclopramide might also be helpful. however, the use of ondansetron might possibly be linked to an increased rate of return to hospital in children. the intravenous preparation of ondansetron may be given orally if clinical judgment warrants. dimenhydrinate, while reducing vomiting, does not appear to have a significant clinical benefit. antibiotics antibiotics are not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly severe or if a susceptible bacterial cause is isolated or suspected. if antibiotics are to be employed, a macrolide (such as azithromycin) is preferred over a fluoroquinolone due to higher rates of resistance to the latter. pseudomembranous colitis, usually caused by antibiotic use, is managed by discontinuing the causative agent and treating it with either metronidazole or vancomycin. bacteria and protozoans that are amenable to treatment include shigella salmonella typhi, and giardia species. in those with giardia species or entamoeba histolytica, tinidazole treatment is recommended and superior to metronidazole. the world health organization (who) recommends the use of antibiotics in young children who have both bloody diarrhea and fever. antimotility agents antimotility medication has a theoretical risk of causing complications, and although clinical experience has shown this to be unlikely, these drugs are discouraged in people with bloody diarrhea or diarrhea that is complicated by fever. loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea. loperamide is not recommended in children, however, as it may cross the immature blood–brain barrier and cause toxicity. bismuth subsalicylate, an insoluble complex of trivalent bismuth and salicylate, can be used in mild to moderate cases, but salicylate toxicity is theoretically possible. epidemiology deaths due to diarrhoeal diseases per million persons in 2012 0–2 3–10 11–18 19–30 31–46 47–80 81–221 222–450 451–606 607–1799 disability-adjusted life year for diarrhea per 100,000 inhabitants in 2004 no data ≤500 500–1000 1000–1500 1500–2000 2000–2500 2500–3000 3000–3500 3500–4000 4000–4500 4500–5000 5000–6000 ≥6000 it is estimated that there were two billion cases of gastroenteritis that resulted in 1.3 million deaths globally in 2015. children and those in the developing world are most commonly affected. as of 2011, in those younger than five, there were about 1.7 billion cases resulting in 0.7 million deaths, with most of these occurring in the world's poorest nations. more than 450,000 of these fatalities are due to rotavirus in children under five years of age. cholera causes about three to five million cases of disease and kills approximately 100,000 people yearly. in the developing world, children less than two years of age frequently get six or more infections a year that result in significant gastroenteritis. it is less common in adults, partly due to the development of acquired immunity. in 1980, gastroenteritis from all causes caused 4.6 million deaths in children, with the majority occurring in the developing world. death rates were reduced significantly (to approximately 1.5 million deaths annually) by 2000, largely due to the introduction and widespread use of oral rehydration therapy. in the us, infections causing gastroenteritis are the second most common infection (after the common cold), and they result in between 200 and 375 million cases of acute diarrhea and approximately ten thousand deaths annually, with 150 to 300 of these deaths in children less than five years of age. society and culture gastroenteritis is associated with many colloquial names, including "montezuma's revenge", "delhi belly", "la turista", and "back door sprint", among others. it has played a role in many military campaigns and is believed to be the origin of the term "no guts no glory". gastroenteritis is the main reason for 3.7 million visits to physicians a year in the united states and 3 million visits in france. in the united states gastroenteritis as a whole is believed to result in costs of us$23 billion per year with that due to rotavirus alone resulting in estimated costs of us$1 billion a year. terminology the first usage of "gastroenteritis" was in 1825. before this time it was commonly known as typhoid fever or "cholera morbus", among others, or less specifically as "griping of the guts", "surfeit", "flux", "colic", "bowel complaint", or any one of a number of other archaic names for acute diarrhea. cholera morbus is a historical term that was used to refer to gastroenteritis rather than specifically cholera. other animals many of the same agents cause gastroenteritis in cats and dogs as in humans. the most common organisms are campylobacter, clostridium difficile, clostridium perfringens, and salmonella. a large number of toxic plants may also cause symptoms. some agents are more specific to a certain species. transmissible gastroenteritis coronavirus (tgev) occurs in pigs resulting in vomiting, diarrhea, and dehydration. it is believed to be introduced to pigs by wild birds and there is no specific treatment available. it is not transmissible to humans.