Age specific aetiological agents of diarrhoea in hospitalized children aged less than five years in Dar es Salaam, Tanzania

Risk Factors for Salmonella Infection in Children under Five Years: A Hospital-Based Study in Kilimanjaro Region, Tanzania

Salmonella is among the causative agents for diarrhea worldwide, but its risk factors in Tanzanian children are poorly understood. A hospital-based cross-sectional study was conducted in Moshi, Kilimanjaro region, from July 2020 to November 2022 among children under five admitted with diarrhea. A questionnaire was administered to all parents/caretakers of the enrolled children. Logistic regression was utilized to analyze the risk factors, with significance at p < 0.05. A total of 306 children were enrolled in the study. The median age was 13.8 months (IQR 8.4-21.8). The majority (58.5%) were males, and 59.5% were from rural areas. Salmonella was identified in eight (2.6%) stool samples, with a higher prevalence in urban than rural areas (4.8% vs. 1.1%; p-value = 0.044). The significant risk factors associated with Salmonella infection among the children included consuming raw milk (adjusted OR = 30.19; 95% CI: 3.94-231.46), using infant formula (adjusted OR = 15.78; 95% CI: 2.98-83.56), undisclosed household income (adjusted OR = 9.98; 95% CI: 2.46-40.12), purchasing eggs direct from the farms (adjusted OR = 7.58; 95%CI: 1.31-43.96), and contact with chickens (adjusted OR = 6.49; 95%CI: 1.25-33.59). These findings highlight the need for targeted interventions to improve food safety, hygiene practices, and socioeconomic conditions.

Epidemiology and multiple colonization of gastrointestinal pathogens in rural Tanzanian children with and without diarrhea: A case-control study

Diarrheal diseases are important causes of morbidity and mortality, worldwide. The occurrence of multiple pathogens in stool samples of symptomatic and asymptomatic individuals in resource-limited countries have been repeatedly described. In this study, we assessed the differentiated effects of combined pathogen detections on recorded symptoms. A case-control study was conducted among 620 under-five-year-old children in rural northeastern Tanzania with emphasis of multiple detection. The median age of children was 11 months (IQR = 7, 20), and 52.1% were male. Cases (50.2%, n = 157) were less likely than controls (64.5%, n = 198) to have multiple colonization with gastrointestinal tract (GIT) pathogens. The children's age was positively associated with the likelihood of harboring multiple GIT pathogens [OR, 1.02, 95% CI = 1.01, 1.04]. Shigella spp./enteroinvasive Escherichia coli (EIEC) [OR = 2.80, 95% CI 1.62, 4.83] and norovirus [OR = 2.04, 95% CI 1.23, 3.39] were more common in cases and were strongly associated with diarrhea, while enteroaggregative E. coli (EAEC) [OR = 0.23, 95%CI 0.17-0.33] were more common in controls. Diarrheal diseases in under-five children from rural Tanzania are likely to be due to infections with Shigella spp./EIEC, and norovirus with strongly age-dependent associations.

High diversity of Salmonella spp. from children with diarrhea, food, and environmental sources in Kilimanjaro - Tanzania: one health approach

Salmonella is one of the most frequent causes of diarrhea globally. This study used a One Health approach to identify Salmonella species in children admitted with diarrhea and tested samples from the cases' household environment to investigate their genetic similarity using whole genome sequencing. Surveillance of hospitalized diarrhea cases among children under 5 years was conducted in rural and urban Moshi Districts in the Kilimanjaro Region of Tanzania from July 2020 through November 2022. Household visits were conducted for every child case whose parent/caregiver provided consent. Stool samples, water, domestic animal feces, meat, and milk were collected and tested for Salmonella. Isolates were sequenced on the Illumina NextSeq platform. Multilocus Sequence Typing and phylogenetic analyses were performed to map the genetic relatedness of the isolates. Salmonella was isolated from 72 (6.0%) of 1,191 samples. The prevalence of Salmonella in children with diarrhea, domestic animal feces, food, and water was 2.6% (n = 8/306), 4.6% (n = 8/174), 4.2% (n = 16/382), and 17.3% (n = 39/225), respectively. Four (1.3%) of the 306 enrolled children had a Salmonella positive sample taken from their household. The common sequence types (STs) were ST1208, ST309, ST166, and ST473. Salmonella Newport was shared by a case and a raw milk sample taken from the same household. The study revealed a high diversity of Salmonella spp., however, we detected a Salmonella clone of ST1208 isolated at least from all types of samples. These findings contribute to understanding the epidemiology of Salmonella in the region and provide insight into potential control of foodborne diseases through a One Health approach.

Epidemiology and Risk Factors for Diarrheagenic Escherichia coli Carriage among Children in Northern Ibadan, Nigeria

Diarrhea is a leading cause of childhood morbidity in Africa, but few studies, focus on bacterial diarrheal etiology including multicountry studies that typically excluded Nigeria. We collected stool specimens from 477 children under 5 years of age, 120 with diarrhea, who were enrolled in our prospective case-control study between November 2015 and August 2019. All were attending primary health clinics on the northern outskirts of Ibadan. Up to 10 Escherichia coli isolates were obtained per specimen, and at least three of them were sequenced using Illumina whole-genome sequence technology. Genomes were assembled using SPAdes and evaluated for quality using QUAST. VirulenceFinder was used to identify virulence genes. The microbiological quality of water from 14 wells within the study area was assessed using total and coliform counts. Diarrheagenic E. coli (DEC) were isolated from 79 (65.8%) cases and 217 (60.8%) control children. A number of hybrid DEC pathotypes, Salmonella spp., Yersinia spp., and all DEC pathotypes except Shiga toxin-producing E. coli were detected, but no pathogen showed association with disease (P > 0.05). Enterotoxigenic E. coli were more commonly recovered from children without diarrhea aged below 6 months but exclusively detected in children with diarrhea aged over 9 months. Temporally linked, genetically similar enteroaggregative E. coli were isolated from children in different households in eight instances. No well water sample drawn in the study was potable. Children in northern Ibadan were commonly colonized with DEC. Access to water, proper sanitation, and vaccination against the prevailing pathogens may be critical for protecting children from the less overt consequences of enteric pathogen carriage.

Antibiotic resistance trends for common bacterial aetiologies of childhood diarrhoea in low- and middle-income countries: A systematic review

Background

Diarrhoea is the second most common cause of death among children under the age of five worldwide. The World Health Organization (WHO) recommends treating diarrhoea with oral rehydration therapy, intravenous fluids for severe dehydration, and zinc supplements. Antibiotics are only recommended to treat acute, invasive diarrhoea. Rising antibiotic resistance has led to a decrease in the effectiveness of treatments for diarrhoea.

Methods

A systematic literature review in PubMed, Web of Science, and EMBASE was conducted to identify articles relevant to antibiotic-resistant childhood diarrhoea. Articles in English published between 1990 to 2020 that described antibiotic resistance patterns of common pathogens causing childhood diarrhoea in low- and middle-income countries were included. The studies were limited to papers that categorized children as 0-5 years or 0-10 years old. The proportion of isolates with resistance to major classes of antibiotics stratified by major WHO global regions and time was determined.

Results

Quantitative data were extracted from 44 articles that met screening criteria; most focused on children under five years. Escherichia coli isolates had relatively high resistance rates to ampicillin and tetracycline in the African (AFR), American (AMR), and Eastern Mediterranean Regions (EMR). There was moderate to high resistance to ampicillin and third generation cephalosporins among Salmonella spp in the AFR, EMR, and the Western Pacific Region (WPR). Resistance rates for ampicillin, co-trimoxazole, and chloramphenicol for Shigella in the AFR started at an alarmingly high rate ( ~ 90%) in 2006 and fluctuated over time. There were limited antibiotic resistance data for Aeromonas, Yersinia, and V. cholerae. The 161 isolates of Campylobacter analysed showed initially low rates of fluoroquinolone resistance with high rates of resistance in recent years, especially in the Southeast Asian Region.

Conclusions

Resistance to inexpensive antibiotics for treatment of invasive diarrhoea in children under ten years is widespread (although data on 6- to 10-year-old children are limited), and resistance rates to fluoroquinolones and later-generation cephalosporins are increasing. A strong regional surveillance system is needed to carefully monitor trends in antibiotic resistance, future studies should include school-aged children, and interventions are needed to reduce inappropriate use of antibiotics for the treatment of community-acquired, non-invasive diarrhoea.

Registration

This systematic review was registered in Prospero (registration number CRD42020204004) in August 2020.

Exploring the Association between Ambient Temperature and Daily Hospital Admissions for Diarrhea in Mopani District, Limpopo Province, South Africa

Diarrhea contributes significantly to global morbidity and mortality. There is evidence that diarrhea prevalence is associated with ambient temperature. This study aimed to determine if there was an association between ambient temperature and diarrhea at a rural site in South Africa. Daily diarrheal hospital admissions (2007 to 2016) at two large district hospitals in Mopani district, Limpopo province were compared to average daily temperature and apparent temperature (Tapp, 'real-feel' temperature that combined temperature, relative humidity, and wind speed). Linear regression and threshold regression, age-stratified to participants ≤5 years and >5 years old, considered changes in daily admissions by unit °C increase in Tapp. Daily ranges in ambient temperature and Tapp were 2-42 °C and -5-34 °C, respectively. For every 1 °C increase in average daily temperature, there was a 6% increase in hospital admissions for diarrhea for individuals of all ages (95% CI: 0.04-0.08; p < 0.001) and a 4% increase in admissions for individuals older than 5 years (95% CI: 0.02-0.05; p < 0.001). A positive linear relationship between average daily Tapp and all daily diarrheal admissions for children ≤5 years old was not statistically significant (95% CI: -0.00-0.03; p = 0.107). Diarrhea is common in children ≤5 years old, however, is more likely triggered by factors other than temperature/Tapp, while it is likely associated with increased temperature in individuals >5 years old. We are limited by lack of data on confounders and effect modifiers, thus, our findings are exploratory. To fully quantify how temperature affects hospital admission counts for diarrhea, future studies should include socio-economic-demographic factors as well as WASH-related data such as personal hygiene practices and access to clean water.

Enteric Pathogens Detected in Children under Five Years Old Admitted with Diarrhea in Moshi, Kilimanjaro, Tanzania

Despite the availability and wide coverage of rotavirus vaccinations in Tanzania, there is still a significant number of diarrhea cases being reported, with some patients requiring hospital admission. We investigated diarrhea-causing pathogens and determined the effect of co-infection on clinical symptoms. Total nucleic acid was extracted from archived stool samples (N = 146) collected from children (0-59 months) admitted with diarrhea in health facilities in Moshi, Kilimanjaro. Pathogen detection was performed using the quantitative polymerase chain reaction with custom TaqMan Array cards. The Poisson model was used to determine the effect of co-infection on clinical presentation during admission. Of all the participants, 56.85% were from rural Moshi with a median age of 11.74 months (IQR: 7.41-19.09). Vomiting (88.36%) and a fever (60.27%) were the most frequent clinical manifestations. At least one diarrhea-associated pathogen was detected in 80.14% (n = 117) of the study population. The most prevalent pathogens were rotavirus 38.36% (n = 56), adenovirus 40/41 19.86% (n = 29), Shigella/EIEC 12.33% (n = 18), norovirus GII 11.44% (n = 17) and Cryptosporidium 9.59% (n = 14). Co-infections were detected in 26.03% of the study population (n = 38). The presence of multiple pathogens in the stool samples of children with diarrhea indicates poor sanitation and may have significant implications for disease management and patient outcomes.

Genetic diversity and Genomic analysis of G3P[6] and equine-like G3P[8] in Children Under-five from Southern Highlands and Eastern Tanzania

Rotavirus group A genomic characterization is critical for understanding the mechanisms of rotavirus diversity, such as reassortment events and possible interspecies transmission. However, little is known about the genetic diversity and genomic relationship of the rotavirus group A strains circulating in Tanzania. The genetic and genomic relationship of RVA genotypes was investigated in children under the age of five. A total of 169 faecal samples were collected from under-five with diarrhea in Mbeya, Iringa and Morogoro regions of Tanzania. The RVA were screened in children under five with diarrhea using reverse transcription PCR for VP7 and VP4, and the G and P genotypes were determined using Sanger dideoxynucleotide cycle sequencing. Whole-genome sequencing was performed on selected genotypes. The overall RVA rate was 4.7% (8/169). The G genotypes were G3 (7/8) and G6 (1/8) among the 8 RVA positives, while the P genotypes were P[6] (4/8) and P[8] (2), and the other two were untypeable. G3P[6] and G3P[8] were the identified genotype combinations. The genomic analysis reveals that the circulating G3P[8] and G3P[6] isolates from children under the age of five with diarrhea had a DS-1-like genome configuration (I2-R2-C2-M2-Ax-N2-T2-E2-H2). The phylogenic analysis revealed that all 11 segments of G3P[6] were closely related to human G3P[6] identified in neighboring countries such as Uganda, Kenya, and other African countries, implying that G3P[6] strains descended from a common ancestor. Whereas, G3P[8] were closely related to previously identified equine-like G3P[P8] from Kenya, Japan, Thailand, Brazil, and Taiwan, implying that this strain was introduced rather than reassortment events. We discovered amino acid differences at antigenic epitopes and N-linked glycosylation sites between the wild type G3 and P[8] compared to vaccine strains, implying that further research into the impact of these differences on vaccine effectiveness is warranted. The phylogenic analysis of VP7 also identified a bovine-like G6. For the first time in Tanzania, we report the emergence of novel equine-like G3 and bovine-like G6 RVA strains, highlighting the importance of rotavirus genotype monitoring and genomic analysis of representative genotypes.

Resistance of Vibrio cholera to antibiotics that inhibit cell wall synthesis: A systematic review and meta-analysis

Objective: Cholera is a challenging ancient disease caused by Vibrio cholera (V. cholera). Antibiotics that prevent cell wall synthesis are among the first known antibiotic groups. Due to its high consumption, V. cholera has developed resistance to the majority of antibiotics in this class. Resistance to recommended antibiotics for the treatment of V. cholera has also increased. In light of the decrease in consumption of certain antibiotics in this group that inhibit cell wall synthesis and the implementation of new antibiotics, it is necessary to determine the antibiotic resistance pattern of V. cholera and to employ the most effective treatment antibiotic. Method: An comprehensive systematic search for relevant articles was conducted in PubMed, Web of Science, Scopus, and EMBASE through October 2020. Stata version 17.1 utilized the Metaprop package to execute a Freeman-Tukey double arcsine transformation in order to estimate weighted pooled proportions. Results: A total of 131 articles were included in the meta-analysis. Ampicillin was the most investigated antibiotic. The prevalence of antibiotic resistance was in order aztreonam (0%), cefepime (0%), imipenem (0%), meropenem (3%), fosfomycin (4%), ceftazidime (5%), cephalothin (7%), augmentin (8%), cefalexin (8%), ceftriaxone (9%), cefuroxime (9%), cefotaxime (15%), cefixime (37%), amoxicillin (42%), penicillin (44%), ampicillin (48%), cefoxitin (50%), cefamandole (56%), polymyxin-B (77%), carbenicillin (95%) respectively. Discussion: Aztreonam, cefepime, and imipenem are the most efficient V. cholera cell wall synthesis inhibitors. There has been an increase in resistance to antibiotics such as cephalothin, ceftriaxone, amoxicillin, and meropenem. Over the years, resistance to penicillin, ceftazidime, and cefotaxime, has decreased.

Antimicrobial resistance in Vibrio cholerae O1/O139 clinical isolates: a systematic review and meta-analysis

OBJECTIVES

Vibrio cholerae O1/O139 is responsible for cholera epidemics; that remains a huge public health menace across the globe. Furthermore, an increasing resistance rate among V. cholerae strains has been reported around the world. Therefore, the objective of this meta-analysis was to evaluate the weighted pooled resistance (WPR) rates in clinical V. cholerae O1/O139 isolates based on different years, areas, antimicrobial susceptibility testing, and resistance rates.

RESEARCH DESIGN AND METHODS

: We searched the studies in PubMed, Scopus, Embase, and Web of Science (until January 2020). Statistical analyses were conducted using STATA software (ver. 14.0).

RESULTS

: A total of 139 studies investigating 24062 V. cholerae O1/O139 isolates were analyzed. The majority of the studies originated in Asia (n=102). The WPR rates were as follows: azithromycin 1%, erythromycin 36%, ciprofloxacin 3%, cotrimoxazole 79%, doxycycline 7%, tetracycline 20%. There was increased resistance to cotrimoxazole, ciprofloxacin, and tetracycline during the 1980 to 2020 years.

CONCLUSIONS

: Temporal changes in antibiotic resistance rate found in this study demonstrated the critical continuous surveillance of antibiotic resistance. Also, ciprofloxacin, azithromycin, gentamicin, cephalexin, imipenem, ofloxacin, and norfloxacin were found to be the best antibiotics against V. cholera, with the highest and the lowest effectiveness resistance rate.

Molecular Study to Detect Escherichia coli in Diarrheic Children and its Antibiotic Resistance

Diarrheal diseases can lead to infections and cause morbidity and mortality in children. Diarrheagenic Escherichia coli (DEC) is an etiological agent, which is considered the major causative agent of diarrhea in children in some developing countries. The aims of this work were to estimate Escherichia coli (E. coli) causing diarrhea in children less than 5 years old, and to detect some biofilm virulence factors and the effect of some antibiotics. For the methodology, a total of 112 specimens were collected from children from two health centers, Al-Zahraa Teaching Hospital and Public Health Laboratory (located in Al-Kut city/ and the Wasit province in Iraq). All specimens were grown on simple and rich media. A total of 43 (38.4%) E. coli isolates were identified using different traditional methods, such as biochemical tests and 16S rRNA sequencing. Polymerase chain reaction (PCR) testing was used to detect some virulence factor genes that play an important role in the pathogenesis of diarrheic E. coli e.g., 16S rRNA, bfpA, and eaeA. In this study, several antibiotics were used to estimate the sensitivity and resistivity of E. coli isolates. A total of 43 isolates were fully identified as E. coli. These samples were used to detect the virulence factor genes, and 31 (72.1%) and 29 (29.4%) isolates carried bfpA and eaeA, respectively. The preponderance of E. coli isolates were completely resistant to penicillin 43 (100%). Additionally, 33 (76.7%) and 27 (62.8%) isolates were resistant to cephalothin and amoxycillin-clavulanic acid, respectively. Furthermore, the isolates of E. coli isolates showed different levels of sensitivity to antibiotics, including polymyxin B 40 (93%), norfloxacin 38 (88.4%), gentamycin 26 (60.4%), and meropenem 22 (51.2%). In conclusion, diarrheagenic E. coli isolates were the prevalent among diarrheic children. Most isolates showed varying results for the presence of virulence factors. In addition, all isolates were resistant to penicillin and sensitive to polymyxin B.

Isolation of Escherichia coli and Its Associated Risk Factor from Diarrheic Children in Wolaita Sodo Town, Southern Ethiopia

INTRODUCTION

Escherichia coli are among the major causes of mortality and morbidity in under-five children in developing nations including Ethiopia.

METHODS

A non-analytical observational study design followed by a purposive sampling technique was conducted from October 2017 to June 2018, to isolate Escherichia coli and determine its associated risk factors from diarrheic children that were admitted to Christian hospital, Wolaita Sodo town. E. coli was confirmed using standard culture and biochemical analyses of the bacterium. In addition, a semi-structured questionnaire was provided to evaluate the potential risk factors that contribute to diarrhea in children.

RESULTS

The overall isolation rate of E. coli in diarrheic children was 61.8% (68/110) (95% CI: 52.1-70.9%). Factors such as age, contact with either animals or manure, negligence to handwashing before a meal with soap, and exclusive breastfeeding at six months (p<0.05) has significant contribution to the prevalence of the E. coli in diarrheic children. The odds of being infected were highest in children whose caretakers had a habit of the negligence of handwashing before the meal (AOR = 6; 95% CI 30.8-49.8%; p = 0.01).

CONCLUSION

Improving the hygienic practices amongst parents of children reduces its Escherichia coli occurrence. Furthermore, awareness of the importance of exclusive breastfeeding to parents of children should be maximized.

Molecular detection of Cryptosporidium: an emerging parasite in different water sources of 2010 flood-affected district Nowshera, Pakistan

Cryptosporidium is a water-borne zoonotic parasite worldwide, usually found in lakes and rivers contaminated with sewage and animal wastes, causing outbreaks of cryptosporidiosis. In this study, 300 water samples were collected from four designated places of flood-affected district Nowshera consist of different water sources to find out the prevalence of Cryptosporidium via polymerase chain reaction (PCR). The overall prevalence of Cryptosporidium was 30.33% (91/300) with more prevalent 44% in drain water and low 5% in bore/tube well water. The prevalence in open well and tap water was recorded 33% and 20%, respectively. The highest prevalence was recorded in summer (June-September). The result of this study ensures enormous contamination of drinking water that requires appropriate treatment, cleaning and filtration to provide safe drinking water. Preventing water-borne disease and proper treatment of water supplies is essential to public health.

Pathogens associated with acute diarrhea, and comorbidity with malaria among children under five years old in rural Burkina Faso

INTRODUCTION

acute diarrhea in children under five years is a public health problem in developing countries and particularly in malaria-endemic areas where both diseases co-exist. The present study examined the etiology of childhood diarrhea and its comorbidity with malaria in a rural area of Burkina Faso.

METHODS

conventional culture techniques, direct stools examination, and viruses´ detection by rapid tests were performed on the fresh stools and microscopy was used to diagnose malaria. Some risk factors were also assessed.

RESULTS

on a total of 191 samples collected, at least one pathogen was identified in 89 cases (46.6%). The proportions of pathogens found on the 89 positive stool samples were parasites 51.69% (46 cases), viruses 39.33% (35 cases), and bacteria 14.61% (13 cases), respectively. The relationship between malaria and infectious diarrhea was significant in viral and parasites causes (p=0.005 and 0.043 respectively). Fever, vomiting and abdominal pain were the major symptoms associated with diarrhea, with 71.51%, 31.72% and 23.66% respectively. The highest viral diarrhea prevalence was reported during the dry season (OR=5.29, 95% CI: 1.74 - 16.07, p=0.001) while parasite diarrhea was more encountered during the rainy season (OR=0.41, 95% CI: 0.33 - 0.87, p=0.011).

CONCLUSION

Giardia spp and rotavirus were the leading cause of acute diarrhea in Nanoro, Burkina Faso with a predominance of rotavirus in children less than 2 years. Parasite and viral diarrhea were the most pathogens associated with malaria. However, the high rate of negative stool samples suggests the need to determine other enteric microorganisms.

Mixed Aetiology of Diarrhoea in Infants Attending Clinics in the North-West Province of South Africa: Potential for Sub-Optimal Treatment

Routine diagnostic methods for the aetiologic agents of diarrhoea in most developing countries are usually not sensitive enough, leading to under-diagnosis. Thus, this study investigated possible mixed diarrhoeal aetiology by using cultures and real-time polymerase chain reactions (PCR) in children younger than four years old in the Northwest Province, South Africa. In total, 505 stool samples were collected from symptomatic and asymptomatic children who were attending three clinics and the Brits hospital in Madibeng District, between September 2016 and December 2017. Rotavirus, norovirus, Campylobacter, Arcobacter, and diarrhoeagenic Escherichia coli (DEC) were targeted. Campylobacter spp. (24.6%), Arcobacter (15.8%) and DEC (19.6%) were detected using PCR; only Campylobacter spp. (29.7%) and DEC (26.9%) were detected through the culture. Campylobacter jejuni (36%), Campylobacter coli (28%), Campylobacter upsalensis (12%), and Arcobacter butzleri (15.8%) were the only spp. of Campylobacter and Arcobacter identified. The eaeA gene (31.4%) of enteropathogenic E. coli/enterohaemorrhagic E. coli (EPEC/EHEC) was the most prevalent DEC virulence gene (VG) identified. Rotavirus and norovirus were detected at 23.4% and 20%, respectively. Mixed viral aetiology (7.3%) and the co-infection of A. butzleri and Campylobacter (49%) were recorded. A mixed bacterial-viral aetiology was observed in 0.6% of the specimens. Sensitive diagnostic procedures like PCR should be considered to provide the best treatment to children experiencing diarrhoea.

Co-infection with Campylobacter and rotavirus in less than 5 year old children with acute gastroenteritis in Nepal during 2017-2018

BACKGROUND

Diarrhoea, although easily curable, is a global cause of death for a half million children every year. Rotavirus and Campylobacter are the most common etiological agents of diarrhoea in children less than 5 years of age. However, in Nepal, these causative agents are not routinely examined for the diagnosis and treatment. The main objective of this study was to determine Campylobacter co-infection associated with rotavirus diarrhoea in children less than 5 years of age.

METHODS

A cross-sectional study was conducted at Kanti Children's Hospital (KCH), Kathmandu, Nepal from November 2017 to April 2018. A total of 303 stool specimens from children affected with diarrhoea were processed to detect rotavirus using a rapid rotavirus antigen detection test kit, and Campylobacter by microscopy, culture and biochemical tests. Antibiotic susceptibility tests of Campylobacter isolates were performed according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines 2015.

RESULTS

Of 303 samples, 91 (30.0%) were positive for co-infection with rotavirus and Campylobacter. Rotavirus mono-infection was detected in 61 (20.1%), and Campylobacter mono-infection was detected in 81 (26.7%) samples. Patient's age, month of infection, untreated water and frequent soil contact were the major risk factors for infections. Clinical features such as > 9 loose motions per day, fever, vomiting, mild to moderate dehydration, diarrhea persisting 6-9 days and presence of mucus in stool were significant (p < 0.05) clinical features, and were more severe in coinfection compared to mono-infections in multivariate analysis.

CONCLUSION

The study shows a high rate of rotavirus and Campylobacter coinfection in children with diarrhoea. Diagnosis based management of diarrhoeal cases can guide the specific treatment.

Factors associated with Salmonella infection in patients with gastrointestinal complaints seeking health care at Regional Hospital in Southern Highland of Tanzania

Background

Salmonellosis remains an important public health problem globally. The disease is among the leading causes of morbidity and mortality in developing countries that experience poor hygiene and lack of access to clean and safe water. There was an increase in reported cases of Salmonellosis in Njombe Region, Southern Highland of Tanzania between 2015 and 2016 based on clinical diagnosis. Nevertheless, little is known about the factors contributing to the transmission of this disease in the region. This study was conducted to determine the prevalence, antimicrobial susceptibility, and factors associated with Salmonella infection among patients who report gastrointestinal complaints.

Methods

A cross-sectional study was conducted from December 2017 to February 2018 among patients with gastrointestinal complaints at Kibena Regional Hospital. Stool samples were submitted for isolation of Salmonella spp. Identification was based on conventional biochemical tests and serotyping to differentiate typhoid and non-typhoid Salmonella (NTS). Antimicrobial susceptibility was performed using the Kirby-Bauer disc diffusion method. Multivariable logistic regression analysis was performed to examine the factors independently associated with Salmonella infection.

Results

The prevalence of Salmonella infection among participants with gastrointestinal complaints was 16.5% (95% CI: 12.7–21.1) of them, 83.7, 95% CI: 70.9–91.5 were NTS while 16.3, 95% CI: 8.5–29.0 were Typhoid Salmonella species.

All isolates were sensitive to ceftriaxone and ciprofloxacin, whereas 27.8 and 100% were resistant to co-trimoxazole and ampicillin respectively. The odd of Salmonella infection was fourfold higher among participants with formal employment (AOR 3.8, 95% CI, 1.53–9.40). Use of water from wells/rivers (AOR 2.2, 95% CI, 1.07–4.45), drinking untreated water (AOR 2.6, 95% CI, 1.21–5.48) and often eating at a restaurant (AOR 3.4, 95% CI, 1.28–8.93) had increased odds of Salmonella infection. Likewise, having abdominal pain (AOR 8.5, 95% CI, 1.81–39.78) and diarrhea (AOR 2.3, 95% CI, 1.12–4.68) were independent symptoms that predict Salmonella infection.

Conclusion

There is a high prevalence of Salmonella infection among people who report gastrointestinal complaints and it is clinically predicated by diarhoea and abdominal pain. Employed participants and those eating at restaurant and drinking unsafe water had higher risk of infection. Salmonella spp. causing gastroenteritis has developed resistance to commonly used antibiotics.

Characterization of non-typhoidal Salmonella isolates from children with acute gastroenteritis, Kolkata, India, during 2000-2016

Non-typhoidal Salmonella (NTS) is an important cause of acute gastroenteritis in children. The study was undertaken to determine the isolation rate, serovar prevalence, antimicrobial resistance (AMR) profiles, and molecular subtypes of NTS from a hospital-based diarrheal disease surveillance in Kolkata, India. Rectal swabs were collected from children (< 5 years of age) with acute gastroenteritis from 2000 to 2016. Samples were processed following standard procedures for identification of NTS. The isolates were tested for antimicrobial susceptibility, AMR genes, plasmid profiles, multilocus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE) subtypes. A total of 99 (1.0%) Salmonella isolates were recovered from 9957 samples processed. Of the 17 Salmonella serovars identified, S. Worthington (33%) was predominant followed by S. Enteritidis (13%), S. Typhimurium (12%), and others. The isolates showed high resistance towards nalidixic acid (43%), ampicillin (34%), third-generation cephalosporins (32%), and azithromycin (25%), while low resistance was observed for fluoroquinolones (2%). Extended-spectrum beta-lactamase production (bla_CTX-M-15 and bla_SHV-12 genes) and azithromycin resistance (mphA gene) were common in S. Worthington, while fluoroquinolone resistance (gyrA and parC mutations) was found in S. Kentucky. Diverse plasmid profiles were observed among the isolates. PFGE analysis identified genetically related strains of each serovar in circulation. MLST also revealed phylogenetically clonal isolates of which S. Worthington ST592 and ciprofloxacin-resistant S. Kentucky ST198 were not reported earlier from India. NTS resistant to current drugs of choice poses a potential public health problem. Continuous monitoring of AMR profiles and molecular subtypes of NTS serovars is recommended for controlling the spread of resistant organisms.

Diarrheal correlates associated with enteric bacterial infections among children below five years in Murang'a County, Kenya

INTRODUCTION

The burden of childhood diarrheal disease has resulted in massive mortality and morbidity globally. Children below 5 years in sub-Saharan Africa are most implicated by diarrheal illnesses resulting in numerous medical consultations, admissions, and deaths despite the disease being easy to prevent and control. The study aimed to determine the correlates of enteric bacterial infection causing diarrhea.

METHODS

During the months of April-October 2017, 163 children below five years presenting with diarrhea were randomly selected in Murang'a and Muriranja's hospitals. Bacterial agents were identified and correlates of diarrhea determined. The study used a hospital-based cross-sectional study design. A standardized questionnaire was used to collect information from the guardian. Statistical analyses were performed using STATA v. 13.

RESULTS

Forty-nine children were infected with enteric pathogenic bacteria (Enterotoxigenic Escherichia coli, Enteropathogenic Escherichia coli, Enteroaggregative Escherichia coli, Salmonella, Shigella, and Vibrio species). Factors associated with infection by these bacteria among the 49 children were evaluated. Children between 0-12 months (OR 0.3, 95% CI 0.1-0.8), those fed exclusively on breast milk (OR 0.3, 95% CI 0.09-0.9) and children weighing 1-5 kilograms (OR 0.2, 95% CI 0.04-0.9) were less likely to be infected with these enteric pathogenic bacteria. Female participants (OR 1.8, 95% CI 1.1-3.4) were nearly twice likely to be infected with enteric pathogenic bacteria. Children who presented with watery stool (OR 0.4, 95% CI 0.2-0.9) or mucoid stool (OR 0.3, 95% CI 0.2-0.7) remained associated with enteric pathogenic bacterial infection but less likely to be infected compared to those who presented with watery-blood stained stools. Piped water (OR 0.01, 95% CI 0.01-0.4) was less associated with enteric bacterial infection than water stored in jerry-cans while storing water without a lid (OR 1.9, 95% CI 1.1-3.7) was more likely to lead to bacterial infection. Hand washing after toilet use (OR 1.6, 95% CI 1.1-2.7) was associated with enteric bacterial infection compared to hand washing before meal preparation.

CONCLUSION

Sanitation, hygiene, nutritional and clinical factors were associated with enteric bacterial infections causing diarrhea among children below five years in the study area. Childhood diarrhea in Murang'a County is a major public health problem.

Etiologies of diarrhea and drug susceptibility patterns of bacterial isolates among under-five year children in refugee camps in Gambella Region, Ethiopia: a case control study

BACKGROUND

Despite substantial global effort and updated clinical management guidelines, diarrhea continues to be among leading worldwide causes of morbidity and mortality in children. Infectious diarrhea, the most common form of diarrhea causes substantial morbidity and mortality among children in developing countries, and the muddled use of antibiotics needs caution due to potential problems of drug-resistance. The aim of this study is to identify etiologies of diarrhea and drug susceptibility patterns of bacterial isolates in under-five children in refugee camps in Gambella Region, Ethiopia.

METHODS

An institution- based matched case control study was conducted using a questionnaire-based interview from June to December 2017 in Pugnido and Teirkidi refugee camps. Stool samples were collected and parasites causing diarrhea were identified by wet mount microscopy. Conventional culture supplemented with API 20E identification kit was used to identify Salmonella and Shigella species. Antibiotic susceptibility of bacterial isolates was investigated by using the disk diffusion method. The association between etiologies and diarrhea was analyzed using McNemar test or Fisher exact test with 95% confidence interval at a level of significance of P < 0.05.

RESULTS

The overall prevalence of enteric pathogens were 55 (41.0%) in diarrhea cases and 18 (13.4%) in healthy controls. The detected etiologies include Giardia lambia (28), Shigella spp. (16), E. hystolyotica/dispar (13), Ascaris lumbricoides (10), Salmonella spp. (6), Cryptosporidium parvum (6), Hymenolepis nana (4) and Isospora belli (3). All isolates were sensitive to kanamycine and ceftazidime. The high resistance rate was observed against ampicillin (100%), amoxicillin (100%), erythromycin (52%), chloramphenicol (47.5%), tetracycline (40.5%), cotrimoxazole (34.8%) and amoxicillin-clavulanic acid (33%). The majorities of the isolates had a low rate of resistance to ciprofloxacin (8.7%), naldxic acid (8.7%) and amikacin (13%).

CONCLUSIONS

Giardia lamblia, E. Hystolytica/dispar, and Shigella spp are the common etiologies of diarrhea in children in the studied refugee camps. The study also showed that significant numbers of bacterial isolates were resistant to the commonly used antimicrobial drugs. Therefore, improving clinical laboratory services and promoting evidence-based drug prescription may reinforce proper use of antibiotics and reduce the emergence of microbial resistance.

Molecular characterization of norovirus infection responsible for acute diarrhea in Congolese hospitalized children under five years old in Brazzaville, Republic of Congo

BACKGROUND

Acute diarrhea is a leading cause of morbidity and mortality among children under five worldwide. As no published data is available on the occurrence of this infection in the Republic of Congo, this study aimed at (1) determining the prevalence and (2) characterizing genotypes of norovirus strains in Brazzaville.

METHODS

From June 2012 to June 2013, stool samples were collected from hospitalized young children with acute gastroenteritis. A total of 545 samples were tested for GI and GII norovirus infections using nested duplex reverse-transcription-polymerase chain reaction and sequencing.

RESULTS

The GI and GII norovirus infection were detected in 148 samples. Males (28%) were not significantly more infected than females (25%). Norovirus infection was found exclusively in children aged under 24 months with a higher prevalence (P=0,048) in the age group of 7-12 months, and throughout the year with a peak in August and September. Genetic diversity of norovirus strains revealed that GII was the most prevalent (87%). No risk factor was significantly associated with norovirus infection.

CONCLUSION

This study showed that noroviruses are important agents responsible for acute diarrhea in Congolese children and highlights the importance of continued surveillance.

Enteropathogens in Under-Five Children with Diarrhea in Health Facilities of Debre Berhan Town, North Shoa, Ethiopia

Background

Diarrheal disease is a major cause of mortality and morbidity for under-five children in Ethiopia. The purpose of this study was to investigate the behavioral and socioeconomic risk factors, etiology, and drug susceptibility of bacteria isolated from under-five children with acute diarrhea who were treated at Debre Berhan Referral Hospital or Health Center in Ethiopia.

Methods

A health facility based cross-sectional study design was used to investigate enteropathogens from 163 under-five children with acute diarrhea. After obtaining written consent from parents or guardians, data were collected using a standardized questionnaire. Freshly passed stool samples were collected for microbiological tests for bacteria and parasites. The chi-square test was used for assessing the relationships of variables.

Results

Enteropathogens were detected among 55.8% (91/163) participants. There was a 46%(75/163) bacterial culture positivity rate and a 9.8%(16/163) prevalence of parasites. The isolated enteropathogens were Escherchia coli, Klebsiella specie, Proteus species, Salmonella species, Shigella species, Enterobacter species, Giardia lamblia, Enteameba histolytica, Ascaris lumbricoides, Trichuris trichiura and Hymnoleps nana. Level of antimicrobial resistance of bacterial isolates ranged from 0 to 87.2%. Poor hand washing and poor cleaning of feeding utensils showed significant association with the presence of enteropathogens.

Conclusion

Bacterial enteropathogens with drug resistance were observed in this study. Continuous health education and promotion about diarrheal disease for mothers/caretakers and regular surveillance of entropathogenes are recommended to reduce under-five mortality.

Antimicrobial resistance of Vibrio cholerae from sub-Saharan Africa: A systematic review

Background

The World Health Assembly adopted the Global Action Plan on Antimicrobial Resistance, which includes improving the knowledge base through surveillance and research. Noteworthily, the World Health Organization has advocated a Global Antimicrobial Resistance Surveillance System to address the plan’s surveillance objective, with most African countries enrolling in or after 2017.

Aim

The aim of this article was to review prior data on antimicrobial resistance of Vibrio cholerae from sub-Saharan Africa with a view for future control and intervention strategies.

Methods

We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (or ‘PRISMA’) guidelines to search the PubMed and African Journals Online databases, as well as additional articles provided by the Nigeria Centre for Disease Control, for articles reporting on the antibiotic susceptibility of V. cholerae between January 2000 and December 2017.

Results

We identified 340 publications, of which only 25 (reporting from 16 countries within the sub-Saharan African region) were eligible. The majority (20; 80.0%) of the cholera toxigenic V. cholerae isolates were of the serogroup O1 of the El Tor biotype with Ogawa and Inaba serotypes predominating. Resistance was predominantly documented to trimethoprim-sulphamethoxazole (50% of the studies), ampicillin (43.3% of the studies), chloramphenicol (43.3% of the studies) and streptomycin (30% of the studies). Resistance mechanisms were reported in 40% of the studies.

Conclusion

Our results demonstrate a documented antimicrobial resistance of V. cholerae to multiple antibiotic classes, including cell wall active agents and antimetabolites with evidence of phenotypic/genotypic resistance to fluoroquinolones.

Clinical features, risk factors, and impact of antibiotic treatment of diarrhea caused by Shigella in children less than 5 years in Manhiça District, rural Mozambique

OBJECTIVES

During the period from December 2007 to November 2012, the epidemiology of diarrhea caused by Shigella was studied among children <5 years of age residing in Manhiça District, Southern Mozambique.

MATERIALS AND METHODS

Children from 0 to 5 years with moderate-to-severe diarrhea (MSD) and less severe diarrhea (LSD) were enrolled along with matched controls (by age, gender, and neighborhood). Age-stratified logistic regression analyses were conducted to identify clinical features and risk factors associated with Shigella positivity in cases of diarrhea. The impact of antibiotic treatment was assessed for patients with known outcome.

RESULTS

A total of 916 cases of MSD and 1979 matched controls, and 431 cases of LSD with equal number of controls were enrolled. Shigella was identified as significant pathogen in both cases of MSD and LSD compared to their respective controls. Shigella was detected in 3.9% (17/431) of LSD compared to 0.5% (2/431) in controls (P=0.001) and in 6.1% (56/916) of MSD cases compared to 0.2% (4/1979) in controls (P<0.0001), with an attributable fraction of 8.55% (95% CI: 7.86-9.24) among children aged 12-23 months. Clinical symptoms associated to Shigella among MSD cases included dysentery, fever, and rectal prolapse. Water availability, giving stored water to child, washing hands before preparing baby's food, and mother as caretaker were the protective factors against acquiring diarrhea caused by Shigella. Antibiotic treatment on admission was associated with a positive children outcome.

CONCLUSION

Shigella remains a common pathogen associated with childhood diarrhea in Mozambique, with dysentery being a significant clinical feature of shigellosis. Adherence to the basic hygiene rules and the use of antibiotic treatment could contribute to the prevention of most of diarrhea due to Shigella.

Characteristics of diarrheagenic Escherichia coli among children under 5 years of age with acute diarrhea: a hospital based study

BACKGROUND

Diarrhea is the leading infectious cause of childhood morbidity and mortality. Among bacterial agents, diarrheagenic Escherichia coli (DEC) is the major causal agent of childhood diarrhea in developing countries, particularly in children under the age of 5 years. Here, we performed a hospital-based prospective study to explore the pathotype distribution, epidemiological characteristics and antibiotic resistance patterns of DEC from < 5-year-old diarrheal children.

METHODS

Between August 2015 and September 2016, 684 stool samples were collected from children (< 5 years old) with acute diarrhea. All samples were cultured and identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) and biochemical tests. PCR was used for subtyping, and enteropathogenic E. coli (EPEC) isolates were identified simultaneously with serology. Furthermore, antimicrobial sensitivity tests and sequencing of antibiotic resistance-related genes were conducted.

RESULTS

DEC strains were identified in 7.9% of the 684 stool samples. Among them, the most commonly detected pathotype was EPEC (50.0% of DEC), of which 77.8% were classified as atypical EPEC (aEPEC). Age and seasonal distribution revealed that DEC tended to infect younger children and to occur in summer/autumn periods. Multidrug-resistant DEC isolates were 66.7%; resistance rates to ampicillin, co-trimoxazole, cefazolin, cefuroxime, cefotaxime, and ciprofloxacin were ≥ 50%. Among 5 carbapenem-resistant DEC, 60.0% were positive for carbapenemase genes (2 blaNDM-1 and 1 blaKPC-2). Among 30 cephalosporin-resistant DEC, 93.3% were positive for extended-spectrum β-lactamase (ESBL) genes, with blaTEM-1 and blaCTX-M-55 being the most common types. However, no gyrA or gyrB genes were detected in 16 quinolone-resistant isolates. Notably, aEPEC, which has not received much attention before, also exhibited high rates of drug resistance (81.0%, 66.7%, and 14.3% for ampicillin, co-trimoxazole , and carbapenem resistance, respectively).

CONCLUSIONS

EPEC was the most frequent DEC pathotype in acute diarrheal children, with aEPEC emerging as a dominant diarrheal agent in central China. Most DEC strains were multidrug-resistant, making even ciprofloxacin unsuitable for empiric treatment against DEC infection. Among carbapenem-resistant DEC strains, those harboring blaNDM-1 and blaKPC-2 were the main causal agents. blaTEM-1 and blaCTX-M-55 were the major genetic determinants associated with high levels of cephalosporin resistance.

Phenotypic and genotypic comparison of salmonellae from diarrhoeic and healthy humans and cattle, Nigeria

The sources and modes of transmission of non-typhoidal Salmonella particularly zoonotic transmission are poorly understood in Africa. This study compared phenotypic and genotypic characteristics of Salmonellae isolated from cattle and humans. Faecal samples of diarrhoeic patients (n = 234), and a healthy population (n = 160), beef cattle at slaughter (n = 250), farms (n = 72) and market (n = 100) were cultured for salmonellae and serotyping and antimicrobial susceptibility were determined. Whole-genome sequence typing (WGST) of selected isolates and bioinformatic analysis were used to identify the multilocus sequence type (MLST), plasmid replicons, antimicrobial resistance genes and genetic relatedness by single nucleotide polymorphism (SNP) analysis. The Salmonella isolates, diarrhoeic patients (n = 17), healthy population (n = 13), cattle (abattoir, n = 67; farms, n = 10; market n = 5), revealed 49 serovars; some serovars were common to humans and cattle. Rare serovars were prevalent: Colindale (cattle and humans); Rubislaw and Bredeney (humans); and Dublin, Give, Eastbourne, Hadar, Marseille, Sundsvall, Bergen, Ekotedo, Carno and Ealing (cattle). The sequence types (ST) include ST 584, ST 198, ST 562 and ST 512 for S. Colindale, S. Kentucky S. Rubislaw and S. Urbana, respectively. Clonal cluster shared by cattle and human WGST isolates was not found. Antimicrobial resistance rates were generally low and towards only chloramphenicol, ampicillin, gentamicin, ciprofloxacin, tetracycline and streptomycin, range 2.7% (chloramphenicol) to 8.9% (streptomycin). Multiply resistant isolates included serovars Kentucky, 4,5,12:i:- and Typhimurium. The study presents a baseline description of the prevalence, serotypes, antimicrobial resistance phenotypes and genetic relatedness of Salmonella isolated from healthy and diarrhoeic humans, and cattle at harvest, on farm and at market. Cattle are a reservoir of diverse salmonellae with shared serovars with humans, but WGST does not support zoonotic transmission. Further study with larger samples is recommended to determine whether epidemiological link exists between cattle and humans.

Correlates of multi-drug non-susceptibility in enteric bacteria isolated from Kenyan children with acute diarrhea

BACKGROUND

Reduced antimicrobial susceptibility threatens treatment efficacy in sub-Saharan Africa, where data on the burden and correlates of antibiotic resistance among enteric pathogens are limited.

METHODS

Fecal samples from children aged 6 mos-15 yrs presenting with acute diarrhea in western Kenya were cultured for bacterial pathogens. HIV-uninfected children with identified Shigella or Salmonella species or pathogenic Escherichia coli (EPEC, ETEC, EAEC or EIEC) were included in this cross-sectional sub-study. Non-susceptibility to ampicillin, ceftriaxone, ciprofloxacin, cotrimoxazole, and tetracycline was determined using MicroScan Walkaway40 Plus. Multivariable log-binomial regression was used to identify correlates of multi-drug non-susceptibility (MDNS, non-susceptibility to ≥ 3 of these antibiotics).

RESULTS

Of 292 included children, median age was 22.5 mos. MDNS was identified in 62.5% of 318 isolates. Non-susceptibility to cotrimoxazole (92.8%), ampicillin (81.3%), and tetracycline (75.0%) was common. Young age (6-24 mos vs. 24-59 mos adjusted prevalence ratio [aPR] = 1.519 [95% confidence interval: 1.19, 1.91]), maternal HIV (aPR = 1.29 [1.01, 1.66]); and acute malnutrition (aPR = 1.28 [1.06, 1.55]) were associated with higher prevalence of MDNS, as were open defecation (aPR = 2.25 [1.13, 4.50]), household crowding (aPR = 1.29 [1.08, 1.53]) and infrequent caregiver hand-washing (aPR = 1.50 [1.15, 1.95]).

CONCLUSIONS

Young age, HIV exposure, acute malnutrition and poor sanitation may increase risk of antibiotic non-susceptible enteric pathogen infections among children in Kenya.

Community-based surveillance of norovirus disease: a systematic review

BACKGROUND

Norovirus is a common cause of infectious gastrointestinal disease. Despite the increased ability to detect norovirus in affected people, the number of reported cases and outbreaks in the community is still substantially underestimated. We undertook a systematic review to determine the nature, scope and scale of community-based surveillance systems which capture information on norovirus disease.

METHODS

We searched MEDLINE, EMBASE and Scopus for studies published between 01 January 1995 and 31 December 2015, using terms relating to norovirus and surveillance. Publications were screened independently by two reviewers using exclusion criteria. Data extraction from included papers was performed using a standardized data extraction form. Outcomes were descriptions of the methods reported in included papers, and any estimates of incidence rate of norovirus disease in each community, stratified by age.

RESULTS

After exclusions, we reviewed 45 papers of which 23 described surveillance studies and 19 included estimates of incidence. The estimates of incidence varied by outcome measure, type of laboratory test and study population. There were two estimates of norovirus hospitalisation; 0.72 and 1.04 per 1000 person-years. Estimates of norovirus disease ranged between 0.024 cases per 1000 person-years and 60 cases per 1000 person-years and estimates of all gastroenteritis varied between 49 and 1100 cases per 1000 person-years.

CONCLUSIONS

Our systematic review found few papers describing community-based surveillance for norovirus disease. Standardised age-specific estimates of norovirus incidence would be valuable for calculating the true global burden of norovirus disease; robust community surveillance systems would be able to produce this information.

TRIAL REGISTRATION

PROSPERO 2016: CRD42016048659 .

Epidemiology and Antibiotic Resistance Phenotypes of Diarrheagenic Escherichia Coli Responsible for Infantile Gastroenteritis in Ouagadougou, Burkina Faso

The emergence and persistence of multidrug-resistant (MDR) diarrheagenic Escherichia coli (DEC) causing acute diarrhea is a major public health challenge in developing countries. The aim of this study was to evaluate the resistance phenotypes of DEC isolated from stool samples collected from children less than 5 years of age with acute diarrhea living in Ouagadougou/Burkina Faso. From August 2013 to October 2015, this study was carried out on 31 DEC strains of our study conducted in "Centre Médical avec Antenne Chirurgicale (CMA)" Paul VI and CMA of Schiphra. DEC were isolated and identified by standard microbiological methods and polymerase chain reaction (PCR) method was used to further characterize them. Antimicrobial susceptibility testing was done based on the disk diffusion method. DEC isolates were high resistant to tetracycline (83.9%), amoxicillin (77.4%), amoxicillin clavulanic acid (77.4%), piperacillin (64.5%), and colistin sulfate (61.3%). The most resistant phenotype represented was the extended spectrum β-lactamase (ESBL) phenotype (67.7%). Aminoglycosides were 100% active on enteroinvasive E. coli (EIEC) and enterohemorrhagic E. coli (EHEC). All the DEC isolates exhibited absolute (100%) sensitivity to ciprofloxacin. Monitoring and studying the resistance profile of DEC to antibiotics are necessary to guide probabilistic antibiotic therapy, especially in pediatric patients.

Association between Childhood Diarrhoeal Incidence and Climatic Factors in Urban and Rural Settings in the Health District of Mbour, Senegal

We assessed the association between childhood diarrhoeal incidence and climatic factors in rural and urban settings in the health district of Mbour in western Senegal. We used monthly diarrhoeal case records among children under five years registered in 24 health facilities over a four-year period (2011-2014). Climatic data (i.e., daily temperature, night temperature and rainfall) for the same four-year period were obtained. We performed a negative binomial regression model to establish the relationship between monthly diarrhoeal incidence and climatic factors of the same and the previous month. There were two annual peaks in diarrhoeal incidence: one during the cold dry season and one during the rainy season. We observed a positive association between diarrhoeal incidence and high average temperature of 36 °C and above and high cumulative monthly rainfall at 57 mm and above. The association between diarrhoeal incidence and temperature was stronger in rural compared to urban settings, while higher rainfall was associated with higher diarrhoeal incidence in the urban settings. Concluding, this study identified significant health-climate interactions and calls for effective preventive measures in the health district of Mbour. Particular attention should be paid to urban settings where diarrhoea was most common in order to reduce the high incidence in the context of climatic variability, which is expected to increase in urban areas in the face of global warming.

Cryptosporidium and Giardia Infections in Children: A Review

Diarrheal disease remains the second leading cause of mortality in children in developing countries. Cryptosporidium is a leading cause and its importance stands to increase as rotavirus vaccine becomes used around the world. Cryptosporidium is particularly problematic in children younger than 2 years old and in the immunocompromised. Giardia lamblia is a common intestinal protozoan that is associated with diarrhea and, perhaps, growth faltering in impoverished settings. This review establishes the current prevalence of these infections in global settings and reviews current diagnosis and management approaches.

Epidemiology of Cryptosporidium in Pediatric Diarrheal Illnesses

CONTEXT

Cryptosporidium spp. is a zoonotic infection, now being recognized as a significant cause of diarrhea in both immunocompetent and immunocompromised hosts. However, there still exist significant knowledge gaps in its estimated global burden, epidemiology, diagnosis and management.

EVIDENCE ACQUISITION

A semi-systematic search was performed across PubMed to select studies on epidemiological burden of cryptosporidium diarrhea using the following keywords- ['crytosporidiosis' OR 'cryptosporidium'] AND ['diarrhea' OR 'diarrhoea']. Articles were included if participants were 'Humans', belonged to pediatric (0-18 y) age group, and were published after 1990. The results were compiled separately for acute and persistent diarrhea.

RESULTS

Cryptosporidium spp is commonly detected in stools of both cases (acute/ persistent diarrhea) and asymptomatic controls. The prevalence is higher in children with diarrhea than non-diarrheal controls (1.7-35% vs 0.3-15%); varying widely across different studies. The positivity rate is higher in younger children (<2 years) suffering from diarrhea. The main symptoms associated with cryptosporidiosis include fever, vomiting and abdominal pain with propensity for prolonged duration of diarrhea. It predisposes to malnutrition, which is also a risk factor for cryptosporidiosis. The prevalence is higher in HIV positive patients; certain socio-demographic factors play a more important role than mere geographical distribution for infection.

CONCLUSION

The high positivity rates during both acute and persistent diarrhea highlights the need to suspect this infection even in immunocompetent children.

Cryptosporidium and Giardia in Africa: current and future challenges

Cryptosporidium and Giardia are important causes of diarrhoeal illness. Adequate knowledge of the molecular diversity and geographical distribution of these parasites and the environmental and climatic variables that influence their prevalence is important for effective control of infection in at-risk populations, yet relatively little is known about the epidemiology of these parasites in Africa. Cryptosporidium is associated with moderate to severe diarrhoea and increased mortality in African countries and both parasites negatively affect child growth and development. Malnutrition and HIV status are also important contributors to the prevalence of Cryptosporidium and Giardia in African countries. Molecular typing of both parasites in humans, domestic animals and wildlife to date indicates a complex picture of both anthroponotic, zoonotic and spill-back transmission cycles that requires further investigation. For Cryptosporidium, the only available drug (nitazoxanide) is ineffective in HIV and malnourished individuals and therefore more effective drugs are a high priority. Several classes of drugs with good efficacy exist for Giardia, but dosing regimens are suboptimal and emerging resistance threatens clinical utility. Climate change and population growth are also predicted to increase both malnutrition and the prevalence of these parasites in water sources. Dedicated and co-ordinated commitments from African governments involving "One Health" initiatives with multidisciplinary teams of veterinarians, medical workers, relevant government authorities, and public health specialists working together are essential to control and prevent the burden of disease caused by these parasites.

Identification and antimicrobial resistance patterns of bacterial enteropathogens from children aged 0-59 months at the University Teaching Hospital, Lusaka, Zambia: a prospective cross sectional study

BACKGROUND

Bacterial diarrhoeal disease is among the most common causes of mortality and morbidity in children 0-59 months at the University Teaching Hospital in Lusaka, Zambia. However, most cases are treated empirically without the knowledge of aetiological agents or antimicrobial susceptibility patterns. The aim of this study was, therefore, to identify bacterial causes of diarrhoea and determine their antimicrobial susceptibility patterns in stool specimens obtained from the children at the hospital.

METHODS

This hospital-based cross-sectional study involved children aged 0-59 months presenting with diarrhoea at paediatrics wards at the University Teaching Hospital in Lusaka, Zambia, from January to May 2016. Stool samples were cultured on standard media for enteropathogenic bacteria, and identified further by biochemical tests. Multiplex polymerase chain reaction was used for characterization of diarrhoeagenic Escherichia coli strains. Antimicrobial susceptibility testing was performed on antibiotics that are commonly prescribed at the hospital using the Kirby-Bauer disc diffusion method, which was performed using the Clinical Laboratory Standards International guidelines.

RESULTS

Of the 271 stool samples analysed Vibrio cholerae 01 subtype and Ogawa serotype was the most commonly detected pathogen (40.8%), followed by Salmonella species (25.5%), diarrhoeagenic Escherichia coli (18%), Shigella species (14.4%) and Campylobacter species (3.5%). The majority of the bacterial pathogens were resistant to two or more drugs tested, with ampicillin and co-trimoxazole being the most ineffective drugs. All diarrhoeagenic Escherichia coli isolates were extended spectrum β-lactamase producers.

CONCLUSION

Five different groups of bacterial pathogens were isolated from the stool specimens, and the majority of these organisms were multidrug resistant. These data calls for urgent revision of the current empiric treatment of diarrhoea in children using ampicillin and co-trimoxazole, and emphasizes the need for continuous antimicrobial surveillance as well as the implementation of prevention programmes for childhood diarrhoea.

Etiology of Diarrhea, Nutritional Outcomes, and Novel Intestinal Biomarkers in Tanzanian Infants

OBJECTIVE

Diarrheal diseases are a leading cause of morbidity and mortality worldwide, but the etiology of diarrhea and its relation to nutritional outcomes in resource-limited settings is poorly defined. We sought to determine the etiology of community-acquired diarrhea in Tanzanian infants and to assess the association with anthropometrics and novel intestinal biomarkers.

METHODS

A convenience sample of infants in a trial of zinc and/or multivitamin supplementation in Tanzania was selected. Subjects were enrolled at age 6 weeks and studied for 18 months. Stool samples were obtained from children with acute diarrhea. A novel, polymerase chain reaction-based TaqMan array was used to screen stool for 15 enteropathogens. A subset of subjects had serum gastrointestinal biomarkers measured.

RESULTS

One hundred twenty-three subjects with diarrhea were enrolled. The mean ± SD age at stool sample collection was 12.4 ± 3.9 months. Thirty-five enteropathogens were identified in 34 (27.6%) subjects: 11 rotavirus, 9 Cryptosporidium spp, 7 Shigella spp, 3 Campylobacter jejuni/coli, 3 heat stable-enterotoxigenic Escherichia coli, and 2 enteropathogenic E coli. Subjects with any identified enteropathogen had significantly lower weight-for-length z scores (-0.55 ± 1.10 vs 0.03 ± 1.30, P = 0.03) at the final clinic visit than those without an identified pathogen. Fifty of the 123 subjects (40.7%) had serum analyzed for antibodies to lipopolysaccharide (LPS) and flagellin. Subjects with any identified enteropathogen had lower immunoglobulin (IgA) antibodies to LPS (0.75 ± 0.27 vs 1.13 ± 0.77, P = 0.01) and flagellin (0.52 ± 0.16 vs 0.73 ± 0.47, P = 0.02) than those without an identified pathogen.

CONCLUSIONS

This quantitative polymerase chain reaction method may allow identification of enteropathogens that place children at higher risk for suboptimal growth. IgA anti-LPS and flagellin antibodies hold promise as emerging intestinal biomarkers.

Longitudinal Comparison of Antibiotic Resistance in Diarrheagenic and Non-pathogenic Escherichia coli from Young Tanzanian Children

Enteroaggregative, enteropathogenic, and enterotoxigenic Escherichia coli contribute significantly to the burden of diarrheal infections particularly in developing countries. Antibiotic resistance is increasingly common among bacterial pathogens including pathogenic E. coli. We assessed the relationship between pathogenic E. coli carriage and resistance to six antibiotics in E. coli isolated from young children in rural Tanzania. We surveyed temporal stability in antibiotic resistance in 2492 E. coli isolated from fecal samples obtained from young children in rural Tanzania collected over a 6 months period. Approximately half of the 377 children sampled were exposed to an azithromycin mass treatment program for trachoma control and half resided in control villages. Children were sampled at baseline, 1-, 3-, and 6 months following azithromycin treatment. We compared resistance to six antibiotics in pathogenic and non-pathogenic strains at the population level, within fecal specimens, and within individuals over time using chi-square tests, paired odds ratios, and logistic regression, respectively. Resistance to ampicillin and trimethoprim/sulfamethoxazole was highly prevalent (>65%). Resistance to 5 of 6 antibiotics tested and multi-drug resistance occurred more frequently in pathogenic isolates (p ≤ 0.001) within fecal specimens and overall. Azithromycin mass treatment exposure was significantly associated with increased odds of carriage of isolates resistant to erythromycin (OR 3.64, p < 0.001) and trimethoprim/sulfamethoxazole (OR 1.60, p < 0.05). Pathogenic isolates were approximately twice as likely to be resistant to erythromycin, ampicillin, or trimethoprim/sulfamethoxazole compared to non-pathogenic isolates from the same fecal specimen. The potential linkage between resistance and virulence in E. coli suggests hygiene and sanitation interventions aimed at reducing disease burden could play a role in controlling transmission of antibiotic resistance.

Prevalence and antibiotic resistance of bacterial pathogens isolated from childhood diarrhea in Beijing, China (2010-2014)

BACKGROUND

Diarrhea is one of the main causes of morbidity and mortality among children less than 5 years of age worldwide, and its causes vary by region. This study aimed to determine the etiologic spectrum, prevalent characteristics and antimicrobial resistance patterns of common enteropathogenic bacteria from diarrheagenic children in Beijing, the capital of China.

METHODS

Stool samples were collected from 2524 outpatients who were aged 0-5 years in Beijing, China during 2010-2014. Microbiological methods, real-time PCR and antimicrobial susceptibility test were used to identify the bacterial causes and antimicrobial resistance patterns in the isolates.

RESULTS

Of the 2524 patients screened, we identified the causes of 269 cases (10.7 %) as follows: diarrheagenic Escherichia coli (4.6 %), Salmonella (4.3 %), Shigella (1.4 %) and Vibrio parahaemolyticus (0.4 %). Atypical EPEC, Salmonella enteritidis, Shigella sonnei and serotype O3:K6 were the most common serogroups or serotypes of the four etiological bacteria. The prevalence of pathogens was correlated with age, season and clinical symptoms. The highest proportion of all causative bacteria was found in children aged 3-5 years and in summer. The clinical symptoms associated with specific bacterial infection, such as fever; abdominal pain; vomiting; and watery, mucus, and bloody stool, were observed frequently in diarrheal patients. Salmonella showed moderate rates of resistance (40-60 %) to ampicillin, nalidixic acid, streptomycin and sulfisoxazole. Resistance to at least three antimicrobials was found in 50 % of isolates. Of the top three serotypes in Salmonella, high-level antimicrobial resistance to single and multiple antibiotics was more common among Salmonella typhimurium and Salmonella 1, 4, [5], 12:i:- than among S. enteritidis. More than 90 % of Shigella isolates showed more alarming resistance to most antibiotics, with a widened spectrum compared to Salmonella.

CONCLUSION

Constant antibiotic surveillance is warranted because the bacteria were highly resistant to various antimicrobials. Our study contributes to the strengthening of the existing surveillance system and provides aid for effective prevention and control strategies for childhood diarrhea.

Role of Enterotoxigenic Bacteroides fragilis in Children Less Than 5 Years of Age With Diarrhea in Tabriz, Iran

Background

Diarrhea is the most frequent health problem among children in developing countries. Defining the etiology of acute diarrhea is critical to disease therapy and prevention. Some anaerobic bacteria such as Enterotoxigenic Bacteroides fragilis (ETBF) strains cause diarrheal disease by production of enterotoxin in children less than 5 years old.

Objectives

This study aimed to evaluate the prevalence of ETBF among common bacteria and viruses causing diarrhea in children aged less than five years.

Materials and Methods

One hundred diarrheal stools were cultured for detection of aerobic and anaerobic pathogen bacteria by direct plating on selective media and antibiotic susceptibility tests were performed according to clinical and laboratory standards institute (CLSI) guidelines on isolates of ETBF. The enterotoxigenic gene among B. fragilis isolates was also investigated using the polymerase chain reaction (PCR) method. Detection of viral pathogens was carried out using the latex agglutination test.

Results

Ten B. fragilis were isolated from 100 diarrheal fecal specimens. All isolates were susceptible to metronidazole, while 10% were susceptible to clindamycin. Four (40%) ETBF were isolated. Rotaviruses (57.2%) and adenoviruses (18.6%) were the most frequently detected etiological agents.

Conclusions

ETBF is one of the etiological agents that may cause diarrhea in children but it is not the commonest of them. Metronidazole is still an effective antibiotic against B. fragilis. Viruses are the most important etiological agents of diarrhea in children less than 5 years of age.

Identification of enteropathogenic Escherichia coli in children with acute diarrheic syndrome from Sucre State, Venezuela

INTRODUCTION

Diarrheagenic Escherichia coli is an important causative agent of acute diarrheic syndrome. 

OBJECTIVE

To identify clonal groups of enteropathogenic E. coli (EPEC), in 485 children with acute diarrhea aged 0 to 10 years attending health care centers in Arismendi, Benítez and Sucre municipalities, Sucre state, Venezuela, from March to December, 2011. 

MATERIALS AND METHODS

After obtaining the informed consent, stool samples were collected. Escherichia coli was identified using standard coproculture methods and serology with polyvalent and monovalent antisera. DNA was isolated, and eae (intimin) and bfpA (bundlin) genes were amplified through two multiplex polymerase chain reactions (PCR). 

RESULTS

The presence of bacterial infection was determined in 39.6% of coprocultures. The prevalence of E. coli was 54.7%; 82.9% of these isolates were positive by serology for the evaluated serogroups and serotypes, which were mostly identified in children between 0 and 2 years (37.9%); 48.6% of E. coli strains amplified the eae gene; of these, 58.8% were classified as typical EPEC (eae+ y bfp+). EPEC II was the most common serogroup (38.7%), with predominance of typical EPEC (60%). In positive strains for eae gene, the β intimin allele was the most frequently identified (74.5%). Only four strains with O157:H7 serotype were identified, which showed no PCR amplification of the eae and bfpA genes. 

CONCLUSION

This study showed the importance of molecular tests to identify diarrheagenic E. coli strains causing clinical conditions of varying severity.

Etiology of Diarrhea in Children Younger Than 5 Years Attending the Bengo General Hospital in Angola

BACKGROUND

Diarrheal disease is among the leading causes of death in children younger than 5 years, especially in developing countries. The aim of this study was to investigate the most frequent etiological agents of diarrhea and its associated factors in children younger than 5 years attending the Bengo General Hospital in Angola.

METHODS

From September 2012 through December 2013, stool samples were collected from 344 children presenting with diarrhea to investigate the presence of viral, bacterial and parasitic agents. Relevant sociodemographic and clinical data were obtained from parents and caregivers.

RESULTS

An enteric pathogen was detected in 66.6% of stool samples: Cryptosporidium spp. (30.0%), rotavirus (25.1%), Giardia lamblia (21.6%), diarrheagenic Escherichia coli (6.3%), Ascaris lumbricoides (4.1%), adenovirus (3.8%), Strongyloides stercoralis (3.5%), astrovirus (2.6%), Hymenolepis nana (1.7%), Entamoeba histolytica/dispar (0.9%), Taenia spp. (0.6%), Trichuris trichiura (0.3%) and Entamoeba histolytica (0.3%). Children younger than 12 months were more frequently infected with Cryptosporidium spp. compared with older children (age: 12-59 months), independently of sex, season, lethargy and wasting [odds ratio (OR): 3.5, 95% confidence interval (95% CI): 2.0-6.2]. Age (OR: 5.0, 95% CI: 2.6-9.3), vomiting (OR: 2.7, 95% CI: 1.5-4.8) and type of admission (inpatients, OR: 0.5, 95% CI: 0.3-0.9) were significantly associated with rotavirus infection.

CONCLUSIONS

This study demonstrates high rates of infection with an enteric pathogen, particularly in children younger than 12 months, emphasizing the need to address diarrheal disease in this age group.

Etiology and Epidemiology of Diarrhea in Hospitalized Children from Low Income Country: A Matched Case-Control Study in Central African Republic

Background

In Sub-Saharan Africa, infectious diarrhea is a major cause of morbidity and mortality. A case-control study was conducted to identify the etiology of diarrhea and to describe its main epidemiologic risk factors among hospitalized children under five years old in Bangui, Central African Republic.

Methods

All consecutive children under five years old hospitalized for diarrhea in the Pediatric Complex of Bangui for whom a parent’s written consent was provided were included. Controls matched by age, sex and neighborhood of residence of each case were included. For both cases and controls, demographic, socio-economic and anthropometric data were recorded. Stool samples were collected to identify enteropathogens at enrollment. Clinical examination data and blood samples were collected only for cases.

Results

A total of 333 cases and 333 controls was recruited between December 2011 and November 2013. The mean age of cases was 12.9 months, and 56% were male. The mean delay between the onset of first symptoms and hospital admission was 3.7 days. Blood was detected in 5% of stool samples from cases. Cases were significantly more severely or moderately malnourished than controls. One of the sought-for pathogens was identified in 78% and 40% of cases and controls, respectively. Most attributable cases of hospitalized diarrhea were due to rotavirus, with an attributable fraction of 39%. Four other pathogens were associated with hospitalized diarrhea: Shigella/EIEC, Cryptosporidium parvum/hominis, astrovirus and norovirus with attributable fraction of 9%, 10%, 7% and 7% respectively. Giardia intestinalis was found in more controls than cases, with a protective fraction of 6%.

Conclusions

Rotavirus, norovirus, astrovirus, Shigella/EIEC, Cryptosporidium parvum/hominis were found to be positively associated with severe diarrhea: while Giardia intestinalis was found negatively associated. Most attributable episodes of severe diarrhea were associated with rotavirus, highlighting the urgent need to introduce the rotavirus vaccine within the CAR’s Expanded Program on Immunization. The development of new medicines, vaccines and rapid diagnostic tests that can be conducted at the bedside should be high priority for low-resource countries.

Infectious diarrhea is a major cause of illness and death among children under five years from low-income country. In order to identify infectious agents associated with diarrhea, we conducted a case-control study in the Pediatric Complex of Bangui, the sole public pediatric hospital from Central African Republic (CAR). A total of 333 hospitalized children with diarrhea and 333 controls were included, controls being pair matched to the cases according to age, sex and neighborhood. At least one of the sought-for pathogens was identified in 80% of hospitalized children, and approximately one in ten cases presented mixed bacterial/viral co-infections. Five pathogens were positively associated with hospitalized diarrhea, namely rotavirus, norovirus, astrovirus, Shigella/EIEC and Cryptosporidium hominis/parvum. Giardia intestinalis was negatively associated with hospitalized diarrhea. A seasonality effect—viruses during the dry season, bacteria and parasites during the rainy season—but also an age effect, were observed, which may guide clinicians in the management of diarrhea. As rotavirus was the leading cause of severe diarrhea, the introduction of the rotavirus vaccine in CAR will certainly provide considerable direct health benefits in terms of reduced illness and deaths. New medicines, vaccines and rapid diagnostic tests that can be conducted bedside should be urgently developed for low-resource countries.

Vaccines for viral and bacterial pathogens causing acute gastroenteritis: Part I: Overview, vaccines for enteric viruses and Vibrio cholerae

Efforts to develop vaccines for prevention of acute diarrhea have been going on for more than 40 y with partial success. The myriad of pathogens, more than 20, that have been identified as a cause of acute diarrhea throughout the years pose a significant challenge for selecting and further developing the most relevant vaccine candidates. Based on pathogen distribution as identified in epidemiological studies performed mostly in low-resource countries, rotavirus, Cryptosporidium, Shigella, diarrheogenic E. coli and V. cholerae are predominant, and thus the main targets for vaccine development and implementation. Vaccination against norovirus is most relevant in middle/high-income countries and possibly in resource-deprived countries, pending a more precise characterization of disease impact. Only a few licensed vaccines are currently available, of which rotavirus vaccines have been the most outstanding in demonstrating a significant impact in a short time period. This is a comprehensive review, divided into 2 articles, of nearly 50 vaccine candidates against the most relevant viral and bacterial pathogens that cause acute gastroenteritis. In order to facilitate reading, sections for each pathogen are organized as follows: i) a discussion of the main epidemiological and pathogenic features; and ii) a discussion of vaccines based on their stage of development, moving from current licensed vaccines to vaccines in advanced stage of development (in phase IIb or III trials) to vaccines in early stages of clinical development (in phase I/II) or preclinical development in animal models. In this first article we discuss rotavirus, norovirus and Vibrio cholerae. In the following article we will discuss Shigella, Salmonella (non-typhoidal), diarrheogenic E. coli (enterotoxigenic and enterohemorragic), and Campylobacter jejuni.

Current Status of Norovirus Infections in Children in Sub-Saharan Africa

Noroviruses are a leading cause of acute sporadic gastroenteritis worldwide. In Sub-Saharan Africa, information regarding norovirus infections in children is scarce. A systematic review of studies performed between 1993 and June 2015 was conducted to establish the genotypic distribution and prevalence of norovirus infections in children (≤17) in Sub-Saharan Africa. Analysis of data from 19 studies involving 8,399 samples from children with symptomatic and nonsymptomatic gastroenteritis revealed prevalence of 12.6% (range 4.6% to 32.4%). The prevalence of norovirus infections was higher in symptomatic children (14.2%) than asymptomatic children (9.2%). Genogroup II (GII) was the most prevalent genogroup accounting for 76.4% of all the reported norovirus infections. The rest of the infections were GI (21.7%) and GI/GII (1.9%). The most common genotypes were GII.4 (65.2%), GI.7 (33.3%), and GI.3 (21.3%). These statistics were calculated from studies carried out in 12 out of 48 Sub-Saharan African countries. Therefore, more studies involving several countries are required to determine fully the epidemiology of noroviruses and their contribution to childhood diarrhoea in Sub-Saharan Africa.

Prevalence of Cryptosporidium parvum/hominis, Entamoeba histolytica and Giardia lamblia among Young Children with and without Diarrhea in Dar es Salaam, Tanzania

Background

Although enteroparasites are common causes of diarrheal illness, few studies have been performed among children in Tanzania. This study aimed to investigate the prevalence of Cryptosporidium parvum/hominis, Entamoeba histolytica and Giardia lamblia among young children in Dar es Salaam, Tanzania, and identify risk factors for infection.

Methodology/Principal Findings

We performed an unmatched case-control study among children < 2 years of age in Dar es Salaam, recruited from August 2010 to July 2011. Detection and identification of protozoans were done by PCR techniques on DNA from stool specimens from 701 cases of children admitted due to diarrhea at the three study hospitals, and 558 controls of children with no history of diarrhea during the last month prior to enrollment. The prevalence of C. parvum/hominis was 10.4% (84.7% C. hominis), and that of G. lamblia 4.6%. E. histolytica was not detected. The prevalence of Cryptosporidium was significantly higher in cases (16.3%) than in controls (3.1%; P < 0.001; OR = 6.2; 95% CI: 3.7–10.4). G. lamblia was significantly more prevalent in controls (6.1%) than in cases (3.4%; P = 0.027; OR = 1.8; 95% CI: 1.1–3.1). Cryptosporidium infection was found more often in HIV-positive (24.2%) than in HIV-negative children (3.9%; P < 0.001; OR = 7.9; 95% CI: 3.1–20.5), and was also associated with rainfall (P < 0.001; OR = 2.41; 95% CI: 1.5–3.8). Among cases, stunted children had significantly higher risk of being infected with Cryptosporidium (P = 0.011; OR = 2.12; 95% CI: 1.2–3.8). G. lamblia infection was more prevalent in the cool season (P = 0.004; OR = 2.2; 95% CI: 1.3–3.8), and more frequent among cases aged > 12 months (P = 0.003; OR = 3.5; 95% CI: 1.5–7.8). Among children aged 7–12 months, those who were breastfed had lower prevalence of G. lamblia infection than those who had been weaned (P = 0.012).

Conclusions

Cryptosporidium infection is common among young Tanzanian children with diarrhea, particularly those living with HIV, and infection is more frequent during the rainy season. G. lamblia is frequently implicated in asymptomatic infections, but rarely causes overt diarrheal illness, and its prevalence increases with age.

Diarrheal diseases are a leading cause of disease and deaths among young children. In Africa they contribute to more than one tenth of childhood deaths. Parasites like Cryptosporidium, Entamoeba histolytica and Giardia lamblia are all common causes of diarrheal illness, but there are few studies on these enteroparasites among Tanzanian children. In this case-control study, we included 701 cases and 558 controls, all < 2 years of age, in Dar es Salaam, Tanzania. We assessed the prevalence of C. parvum/hominis, E. histolytica and G. lamblia by PCR, and the association with potential risk factors such as demographic data, clinical symptoms, HIV status and seasonality. One or more parasites were found in 14.9% of the samples. C. parvum/ hominis and G. lamblia were found in 10.4% and 4.6%, respectively, while E. histolytica was not found in any of the samples. The prevalence of Cryptosporidium was high, particularly in children with HIV, and its prevalence increased during the rainy season. Among cases, Cryptosporidium was found more frequently in stunted children, although any causal association could not be established in the current study. G. lamblia was more often implicated in asymptomatic infections than in overt diarrheal illness. The prevalence of G. lamblia increased with age, and breastfeeding seemed to protect the children from G. lamblia. This study presents relevant information about the prevalence and clinical characteristics of these intestinal parasites in Tanzanian children.

New Algorithm for Managing Childhood Illness Using Mobile Technology (ALMANACH): A Controlled Non-Inferiority Study on Clinical Outcome and Antibiotic Use in Tanzania

Introduction

The decline of malaria and scale-up of rapid diagnostic tests calls for a revision of IMCI. A new algorithm (ALMANACH) running on mobile technology was developed based on the latest evidence. The objective was to ensure that ALMANACH was safe, while keeping a low rate of antibiotic prescription.

Methods

Consecutive children aged 2–59 months with acute illness were managed using ALMANACH (2 intervention facilities), or standard practice (2 control facilities) in Tanzania. Primary outcomes were proportion of children cured at day 7 and who received antibiotics on day 0.

Results

130/842 (15∙4%) in ALMANACH and 241/623 (38∙7%) in control arm were diagnosed with an infection in need for antibiotic, while 3∙8% and 9∙6% had malaria. 815/838 (97∙3%;96∙1–98.4%) were cured at D7 using ALMANACH versus 573/623 (92∙0%;89∙8–94∙1%) using standard practice (p<0∙001). Of 23 children not cured at D7 using ALMANACH, 44% had skin problems, 30% pneumonia, 26% upper respiratory infection and 13% likely viral infection at D0. Secondary hospitalization occurred for one child using ALMANACH and one who eventually died using standard practice. At D0, antibiotics were prescribed to 15∙4% (12∙9–17∙9%) using ALMANACH versus 84∙3% (81∙4–87∙1%) using standard practice (p<0∙001). 2∙3% (1∙3–3.3) versus 3∙2% (1∙8–4∙6%) received an antibiotic secondarily.

Conclusion

Management of children using ALMANACH improve clinical outcome and reduce antibiotic prescription by 80%. This was achieved through more accurate diagnoses and hence better identification of children in need of antibiotic treatment or not. The building on mobile technology allows easy access and rapid update of the decision chart.

Trial Registration

Pan African Clinical Trials Registry PACTR201011000262218

Diarrheal Disease in Rural Mozambique: Burden, Risk Factors and Etiology of Diarrheal Disease among Children Aged 0-59 Months Seeking Care at Health Facilities

Background

Diarrheal disease remains a leading cause of illness and death, particularly in low-income countries. Its burden, microbiological causes and risk factors were examined in children aged 0–59 months living in Manhiça, rural southern Mozambique.

Methods

Trends of diarrhea-related burden of disease were estimated during the period 2001–2012. A prospective, age-stratified and matched (by age, gender and geographical origin), case-control study was conducted during 2007–2011. Clinical, epidemiology, anthropometric measurement and fecal samples obtained from recruited children were used to estimate moderate-to-severe diarrhea (MSD) weighted attributable fractions.

Results

Over the last decade the incidence of acute diarrhea has dropped by about 80%. Incidence of MSD per 100 child years at risk for the period 2007–2011 was 9.85, 7.73 and 2.10 for children aged 0–11, 12–23 and 24–59 months respectively. By adjusted population attributable fractions, most cases of MSD were due to rotavirus, Cryptosporidium, ETEC ST (ST only or ST/LT), Shigella and Adenovirus 40/41. Washing hands and having facilities to dispose child’s stools were associated with a reduced risk of MSD, while giving stored water to the child was associated with an increased risk of MSD.

Conclusions

Despite the predominantly decreasing trends observed throughout the last decade, diarrheal diseases remain today a major cause of morbidity among children aged 0–59 months living in this rural Mozambican area. Rotavirus, cryptosporidium, Shigella, ETEC ST and Adenovirus 40/41 were the most important aetiologies of MSD. Thus, well-known preventive strategies such as washing hands, improving the treatment of stored water, having facilities to dispose children stools, and accelerating the introduction of the rotavirus vaccine should be promoted on a wider scale to reduce the current burden of diarrheal diseases.

Analysis of bacterial pathogens causing acute diarrhea on the basis of sentinel surveillance in Shanghai, China, 2006-2011

Acute diarrhea is the most common infectious disease worldwide and its causes vary from one region to another. We aimed to analyze the spectrum and epidemiological characteristics of pathogens from 22,386 outpatients with acute diarrhea on the basis of surveillance data from Shanghai, China, during 2006-2011. The following 8 pathogens were isolated and identified using standard methods: Salmonella, Shigella, Vibrio cholerae, V. parahaemolyticus, enteropathogenic Escherichia coli, enterotoxigenic E. coli, enteroinvasive E. coli, and enterohemorrhagic E. coli. In total, 2,234 strains of pathogens were obtained and the overall isolation rate of these 8 pathogens gradually decreased from 17.1% in 2006 to 7.4% in 2011. V. parahaemolyticus was the most frequently identified pathogen, followed by Shigella and Salmonella. The isolation rate of V. parahaemolyticus notably varied by season, whereas Salmonella and Shigella infections showed little seasonal variation. Age-related variation was also observed. V. parahaemolyticus infection occurred more often in patients aged 20-40 years. S. enterica serovar Enteritidis and S. flexneri were the most common serotypes of Salmonella and Shigella, respectively. The descending trend observed in the isolation rate of pathogens from the current surveillance suggests an urgent requirement or improvement.