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Levine MM, Nasrin D, Acácio S, Bassat Q, Powell H, Tennant SM, Sow SO, Sur D, Zaidi AKM, Faruque ASG, Hossain MJ, Alonso PL, Breiman RF, O'Reilly CE, Mintz ED, Omore R, Ochieng JB, Oundo JO, Tamboura B, Sanogo D, Onwuchekwa U, Manna B, Ramamurthy T, Kanungo S, Ahmed S, Qureshi S, Quadri F, Hossain A, Das SK, Antonio M, Saha D, Mandomando I, Blackwelder WC, Farag T, Wu Y, Houpt ER, Verweiij JJ, Sommerfelt H, Nataro JP, Robins-Browne RM, Kotloff KL. Diarrhoeal disease and subsequent risk of death in infants and children residing in low-income and middle-income countries: analysis of the GEMS case-control study and 12-month GEMS-1A follow-on study. Lancet Glob Health 2019; 8:e204-e214. [PMID: 31864916 PMCID: PMC7025325 DOI: 10.1016/s2214-109x(19)30541-8] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/05/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
Background The Global Enteric Multicenter Study (GEMS) was a 3-year case-control study that measured the burden, aetiology, and consequences of moderate-to-severe diarrhoea (MSD) in children aged 0–59 months. GEMS-1A, a 12-month follow-on study, comprised two parallel case-control studies, one assessing MSD and the other less-severe diarrhoea (LSD). In this report, we analyse the risk of death with each diarrhoea type and the specific pathogens associated with fatal outcomes. Methods GEMS was a prospective, age-stratified, matched case-control study done at seven sites in Africa and Asia. Children aged 0–59 months with MSD seeking care at sentinel health centres were recruited along with one to three randomly selected matched community control children without diarrhoea. In the 12-month GEMS-1A follow-on study, children with LSD and matched controls, in addition to children with MSD and matched controls, were recruited at six of the seven sites; only cases of MSD and controls were enrolled at the seventh site. We compared risk of death during the period between enrolment and one follow-up household visit done about 60 days later (range 50–90 days) in children with MSD and LSD and in their respective controls. Approximately 50 pathogens were detected using, as appropriate, classic bacteriology, immunoassays, gel-based PCR and reverse transcriptase PCR, and quantitative real-time PCR (qPCR). Specimens from a subset of GEMS cases and controls were also tested by a TaqMan Array Card that compartmentalised probe-based qPCR for 32 enteropathogens. Findings 223 (2·0%) of 11 108 children with MSD and 43 (0·3%) of 16 369 matched controls died between study enrolment and the follow-up visit at about 60 days (hazard ratio [HR] 8·16, 95% CI 5·69–11·68, p<0·0001). 12 (0·4%) of 2962 children with LSD and seven (0·2%) of 4074 matched controls died during the follow-up period (HR 2·78, 95% CI 0·95–8·11, p=0·061). Risk of death was lower in children with dysenteric MSD than in children with non-dysenteric MSD (HR 0·20, 95% CI 0·05–0·87, p=0·032), and lower in children with LSD than in those with non-dysenteric MSD (HR 0·29, 0·14–0·59, p=0·0006). In children younger than 24 months with MSD, infection with typical enteropathogenic Escherichia coli, enterotoxigenic E coli encoding heat-stable toxin, enteroaggregative E coli, Shigella spp (non-dysentery cases), Aeromonas spp, Cryptosporidium spp, and Entamoeba histolytica increased risk of death. Of 61 deaths in children aged 12–59 months with non-dysenteric MSD, 31 occurred among 942 children qPCR-positive for Shigella spp and 30 deaths occurred in 1384 qPCR-negative children (HR 2·2, 95% CI 1·2–3·9, p=0·0090), showing that Shigella was strongly associated with increased risk of death. Interpretation Risk of death is increased following MSD and, to a lesser extent, LSD. Considering there are approximately three times more cases of LSD than MSD in the population, more deaths are expected among children with LSD than in those with MSD. Because the major attributable LSD-associated and MSD-associated pathogens are the same, implementing vaccines and rapid diagnosis and treatment interventions against these major pathogens are rational investments. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Myron M Levine
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Dilruba Nasrin
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sozinho Acácio
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Quique Bassat
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain; Consorcio de Investigación Biomédíca en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Helen Powell
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sharon M Tennant
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samba O Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Anita K M Zaidi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan; Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Abu S G Faruque
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - M Jahangir Hossain
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Pedro L Alonso
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Robert F Breiman
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; Global Disease Detection Division, Kenya Office of the US Centers for Disease Control and Prevention, Nairobi, Kenya; Global Health Institute, Emory University, Atlanta, GA, USA
| | - Ciara E O'Reilly
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Centers for Disease Control and Prevention Country Office, Addis Ababa, Ethiopia
| | - Eric D Mintz
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Richard Omore
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - John B Ochieng
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Joseph O Oundo
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya; London School of Hygiene and Tropical Medicine, Harar, Ethiopia
| | | | - Doh Sanogo
- Centre pour le Développement des Vaccins, Bamako, Mali
| | | | - Byomkesh Manna
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Thandavarayan Ramamurthy
- National Institute of Cholera and Enteric Diseases, Kolkata, India; Translational Health Science and Technology Institute, Faridabad, India
| | - Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Shahnawaz Ahmed
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Shahida Qureshi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Farheen Quadri
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan; PPD, San Diego, CA, USA
| | - Anowar Hossain
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh; Square Hospitals, Mohakhali, Dhaka, Bangladesh
| | - Sumon K Das
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh; Menzies School of Health Research, Casuarina, NT, Australia
| | - Martin Antonio
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Debasish Saha
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia; GlaxoSmithKline Vaccines, Wavre, Belgium
| | - Inacio Mandomando
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - William C Blackwelder
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tamer Farag
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Yukun Wu
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Sanofi Pasteur, Swiftwater, PA, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jaco J Verweiij
- Department of Parasitology, Leiden University Medical Center, Leiden, Netherlands; Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Norwegian Institute of Public Health, Oslo, Norway
| | - James P Nataro
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Roy M Robins-Browne
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
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