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Omore R, Awuor AO, Ogwel B, Okonji C, Sonye C, Oreso C, Akelo V, Amollo M, Ogudi I, Anyango RO, Audi M, Apondi E, Riziki L, Ambila L, Dilruba N, Muok E, Munga S, Ochieng JB, Kotloff KL. The Enterics for Global Health (EFGH) Shigella Surveillance Study in Kenya. Open Forum Infect Dis 2024; 11:S91-S100. [PMID: 38532953 PMCID: PMC10962753 DOI: 10.1093/ofid/ofad654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
Background Although Shigella is an important cause of diarrhea in Kenyan children, robust research platforms capable of conducting incidence-based Shigella estimates and eventual Shigella-targeted clinical trials are needed to improve Shigella-related outcomes in children. Here, we describe characteristics of a disease surveillance platform whose goal is to support incidence and consequences of Shigella diarrhea as part of multicounty surveillance aimed at preparing sites and assembling expertise for future Shigella vaccine trials. Methods We mobilized our preexisting expertise in shigellosis, vaccinology, and diarrheal disease epidemiology, which we combined with our experience conducting population-based sampling, clinical trials with high (97%-98%) retention rates, and healthcare utilization surveys. We leveraged our established demographic surveillance system (DSS), our network of healthcare centers serving the DSS, and our laboratory facilities with staff experienced in performing microbiologic and molecular diagnostics to identify enteric infections. We joined these resources with an international network of sites with similar capabilities and infrastructure to form a cohesive scientific network, designated Enterics for Global Health (EFGH), with the aim of expanding and updating our knowledge of the epidemiology and adverse consequences of shigellosis and enriching local research and career development priorities. Conclusions Shigella surveillance data from this platform could help inform Shigella vaccine trials.
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Affiliation(s)
- Richard Omore
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Alex O Awuor
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Billy Ogwel
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Caleb Okonji
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Catherine Sonye
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Caren Oreso
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Victor Akelo
- Department of Clinical Medicine, Liverpool School of Tropical Medicine, Kisumu, Kenya
| | - Manase Amollo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Isaiah Ogudi
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Raphael O Anyango
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Marjorie Audi
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Evans Apondi
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Laura Riziki
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lilian Ambila
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Nasrin Dilruba
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Erick Muok
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Stephen Munga
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - John B Ochieng
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Biswas D, Asadullah A, Khan SH, Khan ZH, Islam MT, Khan AI, Qadri F, Nelson EJ, Watt MH, Leung DT. Qualitative Assessment of a Smartphone-Based Mobile Health Tool to Guide Diarrhea Management in Bangladesh. Am J Trop Med Hyg 2024; 110:159-164. [PMID: 38081051 PMCID: PMC10793020 DOI: 10.4269/ajtmh.23-0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/24/2023] [Indexed: 01/05/2024] Open
Abstract
Diarrheal diseases are a major cause of morbidity and mortality in children worldwide and a significant contributor to antimicrobial resistance. In the absence of laboratory diagnostics to establish diarrhea etiology, electronic clinical decision support tools can help physicians make informed treatment decisions for children with diarrhea. In Bangladesh, we assessed the feasibility and acceptability of an electronic Diarrhea Etiology Prediction algorithm (DEP tool) embedded into a rehydration calculator, which was designed to help physicians manage children with diarrhea, including decisions on antibiotic use. A team of Bangladeshi anthropologists conducted in-depth interviews with physicians (N = 13) in three public hospitals in Bangladesh about their experience using the tool in the context of a pilot trial. Physicians expressed positive opinions of the DEP tool. Participants perceived the tool to be simple and easy to use, with structured guidance on collecting and entering clinical data from patients. Significant strengths of the tool were as follows: standardization of protocol, efficiency of clinical decision-making, and improved clinical practice. Participants also noted barriers that might restrict the widespread impact of the tool, including physicians' reluctance to use an electronic tool for clinical decision-making, increasing work in overburdened healthcare settings, unavailability of a smartphone, and patients' preferences for antibiotics. We conclude that an electronic clinical decision support tool is a promising method for improving diarrheal management and antibiotic stewardship. Future directions include developing and implementing such a tool for informal healthcare physicians in low-resource settings, where families may first seek care for pediatric diarrhea.
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Affiliation(s)
- Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Asadullah Asadullah
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sazzad Hossain Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Zahid Hasan Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Taufiqul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ashraful Islam Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Eric J. Nelson
- Departments of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Daniel T. Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah
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3
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Stenhouse GE, Keddy KH, Bengtsson RJ, Hall N, Smith AM, Thomas J, Iturriza-Gómara M, Baker KS. The genomic epidemiology of shigellosis in South Africa. Nat Commun 2023; 14:7715. [PMID: 38001075 PMCID: PMC10673971 DOI: 10.1038/s41467-023-43345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Shigellosis, a leading cause of diarrhoeal mortality and morbidity globally, predominantly affects children under five years of age living in low- and middle-income countries. While whole genome sequence analysis (WGSA) has been effectively used to further our understanding of shigellosis epidemiology, antimicrobial resistance, and transmission, it has been under-utilised in sub-Saharan Africa. In this study, we applied WGSA to large sub-sample of surveillance isolates from South Africa, collected from 2011 to 2015, focussing on Shigella flexneri 2a and Shigella sonnei. We find each serotype is epidemiologically distinct. The four identified S. flexneri 2a clusters having distinct geographical distributions, and antimicrobial resistance (AMR) and virulence profiles, while the four sub-Clades of S. sonnei varied in virulence plasmid retention. Our results support serotype specific lifestyles as a driver for epidemiological differences, show AMR is not required for epidemiological success in S. flexneri, and that the HIV epidemic may have promoted Shigella population expansion.
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Affiliation(s)
- George E Stenhouse
- Clinical Infection, Microbiology, and Immunology, University of Liverpool, Liverpool, UK.
| | | | - Rebecca J Bengtsson
- Clinical Infection, Microbiology, and Immunology, University of Liverpool, Liverpool, UK
| | - Neil Hall
- Earlham Institute, Norwich Research Park, NR4 7UZ, Norwich, UK
| | - Anthony M Smith
- Centre for Enteric Diseases, National Institute for Communicable Diseases (NICD), Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Department of Medical Microbiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Juno Thomas
- Centre for Enteric Diseases, National Institute for Communicable Diseases (NICD), Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Miren Iturriza-Gómara
- Clinical Infection, Microbiology, and Immunology, University of Liverpool, Liverpool, UK
| | - Kate S Baker
- Clinical Infection, Microbiology, and Immunology, University of Liverpool, Liverpool, UK.
- Department of Genetics, University of Cambridge, CB23EH, Cambridge, UK.
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4
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Garbern SC, Islam MT, Islam K, Ahmed SM, Brintz BJ, Khan AI, Taniuchi M, Platts-Mills JA, Qadri F, Leung DT. Derivation and External Validation of a Clinical Prediction Model for Viral Diarrhea Etiology in Bangladesh. Open Forum Infect Dis 2023; 10:ofad295. [PMID: 37404954 PMCID: PMC10316693 DOI: 10.1093/ofid/ofad295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/26/2023] [Indexed: 07/06/2023] Open
Abstract
Background Antibiotics are commonly overused for diarrheal illness in many low- and middle-income countries, partly due to a lack of diagnostics to identify viral cases, in which antibiotics are not beneficial. This study aimed to develop clinical prediction models to predict risk of viral-only diarrhea across all ages, using routinely collected demographic and clinical variables. Methods We used a derivation dataset from 10 hospitals across Bangladesh and a separate validation dataset from the icddr,b Dhaka Hospital. The primary outcome was viral-only etiology determined by stool quantitative polymerase chain reaction. Multivariable logistic regression models were fit and externally validated; discrimination was quantified using area under the receiver operating characteristic curve (AUC) and calibration assessed using calibration plots. Results Viral-only diarrhea was common in all age groups (<1 year, 41.4%; 18-55 years, 17.7%). A forward stepwise model had AUC of 0.82 (95% confidence interval [CI], .80-.84) while a simplified model with age, abdominal pain, and bloody stool had AUC of 0.81 (95% CI, .78-.82). In external validation, the models performed adequately although less robustly (AUC, 0.72 [95% CI, .70-.74]). Conclusions Prediction models consisting of 3 routinely collected variables can accurately predict viral-only diarrhea in patients of all ages in Bangladesh and may help support efforts to reduce inappropriate antibiotic use.
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Affiliation(s)
- Stephanie Chow Garbern
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | | | - Kamrul Islam
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Sharia M Ahmed
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ben J Brintz
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Firdausi Qadri
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Miti S, Chilyabanyama ON, Chisenga CC, Chibuye M, Bosomprah S, Mumba C, Chitondo S, Siziya S, Cohen D, Chilengi R, Simuyandi M. Sensitivity and predictive value of dysentery in diagnosing shigellosis among under five children in Zambia. PLoS One 2023; 18:e0279012. [PMID: 36827347 PMCID: PMC9955635 DOI: 10.1371/journal.pone.0279012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 11/28/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Shigella is a leading cause of bacterial diarrhea morbidity and mortality affecting mainly children under five in the developing world. In Zambia, Shigella has a high prevalence of 34.7% in children with diarrhea and an attributable fraction of 6.7% in Zambian children with moderate to severe diarrhea. Zambian diarrhea management guidelines and the health ministry reporting tool Health Management Information System (HMIS) heavily rely on the WHO clinical classification of dysentery to potentially identify and estimate the burden of Shigella in children. This reliance on clinical dysentery as a proxy to shigellosis in under five children may be resulting in gross under-estimation of shigella disease burden in Zambia. METHODS We used existing laboratory and clinical data to examine the sensitivity and predictive value of dysentery to correctly identify Shigella infection in under five children with PCR confirmed Shigella infection in Lusaka and Ndola districts, Zambia. RESULTS Clinical dysentery had a sensitivity of 8.5% (34/401) in identifying under five children with Shigella by stool PCR. Dysentery was able to correctly classify Shigella in 34 of 68 bloody stool samples giving a corresponding positive predictive value of 50%. Of the 1087 with non-bloody diarrhea, 720 did not have Shigella giving a negative predictive value of 66.2%. CONCLUSIONS Use of clinical dysentery as a screening symptom for Shigella infection in children under five presenting with moderate to severe diarrhea has low sensitivity and low positive predictive value respectively. Clinical dysentery as a screening symptom for Shigella contributes to gross under diagnosis and reporting of Shigella infection among under five children in Zambia. Further research is required to better inform practice on more accurate methods or tools to use in support of routine diagnosis, particularly in low middle-income settings where laboratory diagnosis remains a challenge.
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Affiliation(s)
- Sam Miti
- Arthur Davison Children’s Hospital, Ndola, Zambia,Center for Infectious Disease Research in Zambia, Lusaka, Zambia,School of Medicine, Copperbelt University, Ndola, Zambia,Tropical Diseases Research Center, Ndola, Zambia,* E-mail:
| | | | | | - Mwelwa Chibuye
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Samuel Bosomprah
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia,Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana
| | | | | | - Seter Siziya
- School of Medicine, Copperbelt University, Ndola, Zambia
| | - Dani Cohen
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Roma Chilengi
- Center for Infectious Disease Research in Zambia, Lusaka, Zambia
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6
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St Jean DT, Rogawski McQuade ET, Edwards JK, Thompson P, Thomas J, Becker-Dreps S. Effect of early life antibiotic use on serologic responses to oral rotavirus vaccine in the MAL-ED birth cohort study. Vaccine 2022; 40:2580-2587. [PMID: 35341645 PMCID: PMC9045361 DOI: 10.1016/j.vaccine.2022.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/06/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Oral rotavirus vaccine efficacy is lower in low- and middle-income countries (LMICs) than in high-income countries. The degree to which antibiotic use impacts rotavirus vaccine immunogenicity in LMICs is unknown. Using data from a multisite prospective birth cohort study of malnutrition and enteric disease, MAL-ED, we examined the effect of early life antibiotic use on the immune response to rotavirus vaccine. METHODS We assessed whether antibiotic use from birth up to 7 days following rotavirus vaccine series completion was associated with rotavirus seropositivity at 7 months of age in Brazil, Peru, and South Africa using a modified Poisson regression. We then used parametric g-computation to estimate the impact of hypothetical interventions that treated all children and alternatively prevented inappropriate antibiotic treatments on seropositivity. RESULTS Of 537 children, 178 (33%) received at least one antibiotic course during the exposure window. Probability of seropositivity was 40% higher among children who had at least one course of antibiotics compared with those with no antibiotic exposure (PR: 1.40, 95% CI: 1.04, 1.89). There was no significant difference by the number of antibiotic courses received or total duration of antibiotics. Treating all children with antibiotics would be associated with a 19% (95% CI: 18%, 21%) absolute increase in seropositivity at 7 months. In contrast, removing inappropriate antibiotics would result in a 4% absolute reduction (95% CI: -5%, -2%) in seropositivity. CONCLUSIONS Early life antibiotic use was associated with increased seropositivity. However, a hypothetical intervention to remove inappropriate antibiotics would have little effect on overall seropositivity. Further investigation into the underlying mechanisms of antibiotic use on the infant gut microbiome and immune response are needed.
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Affiliation(s)
- Denise T St Jean
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peyton Thompson
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James Thomas
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sylvia Becker-Dreps
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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7
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Garbern SC, Nelson EJ, Nasrin S, Keita AM, Brintz BJ, Gainey M, Badji H, Nasrin D, Howard J, Taniuchi M, Platts-Mills JA, Kotloff KL, Haque R, Levine AC, Sow SO, Alam NH, Leung DT. External validation of a mobile clinical decision support system for diarrhea etiology prediction in children: a multicenter study in Bangladesh and Mali. eLife 2022; 11:72294. [PMID: 35137684 PMCID: PMC8903833 DOI: 10.7554/elife.72294] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 02/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Diarrheal illness is a leading cause of antibiotic use for children in low- and middle-income countries. Determination of diarrhea etiology at the point-of-care without reliance on laboratory testing has the potential to reduce inappropriate antibiotic use. Methods: This prospective observational study aimed to develop and externally validate the accuracy of a mobile software application ('App') for the prediction of viral-only etiology of acute diarrhea in children 0-59 months in Bangladesh and Mali. The App used a previously derived and internally validated model consisting of patient-specific ('present patient') clinical variables (age, blood in stool, vomiting, breastfeeding status, and mid-upper arm circumference) as well as location-specific viral diarrhea seasonality curves. The performance of additional models using the 'present patient' data combined with other external data sources including location-specific climate, data, recent patient data, and historical population-based prevalence were also evaluated in secondary analysis. Diarrhea etiology was determined with TaqMan Array Card using episode-specific attributable fraction (AFe) >0.5. Results: Of 302 children with acute diarrhea enrolled, 199 had etiologies above the AFe threshold. Viral-only pathogens were detected in 22% of patients in Mali and 63% in Bangladesh. Rotavirus was the most common pathogen detected (16% Mali; 60% Bangladesh). The present patient + viral seasonality model had an AUC of 0.754 (0.665-0.843) for the sites combined, with calibration-in-the-large α=-0.393 (-0.455 - -0.331) and calibration slope β=1.287 (1.207 - 1.367). By site, the present patient + recent patient model performed best in Mali with an AUC of 0.783 (0.705 - 0.86); the present patient + viral seasonality model performed best in Bangladesh with AUC 0.710 (0.595 - 0.825). Conclusion: The App accurately identified children with high likelihood of viral-only diarrhea etiology. Further studies to evaluate the App's potential use in diagnostic and antimicrobial stewardship are underway. Funding: Funding for this study was provided through grants from the Bill and Melinda Gates Foundation (OPP1198876) and the National Institute of Allergy and Infectious Diseases (R01AI135114). Several investigators were also partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK116163). This investigation was also supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in the study design, data collection, data analysis, interpretation of data, or in the writing or decision to submit the manuscript for publication.
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Affiliation(s)
| | - Eric J Nelson
- Department of Pediatrics, University of Florida, Gainesville, United States
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Ben J Brintz
- Department of Internal Medicine, University of Utah, Salt Lake City, United States
| | - Monique Gainey
- Department of Emergency Medicine, Rhode Island Hospital, Providence, United States
| | - Henry Badji
- Center for Vaccine Development, Bamako, Mali
| | - Dilruba Nasrin
- Center for Vaccine Development and Global Healt, University of Maryland School of Medicine, Baltimore, United States
| | - Joel Howard
- Department of Pediatrics, University of Kentucky, Lexington, United States
| | - Mami Taniuchi
- Department of Medicine, University of Virginia, Charlottesville, United States
| | | | - Karen L Kotloff
- Department of Pediatrics, University of Maryland, Baltimore, United States
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Adam C Levine
- Department of Emergency Medicine, Brown University, Providence, United States
| | - Samba O Sow
- Center for Vaccine Development, Bamako, Mali
| | - Nur Haque Alam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Daniel T Leung
- Internal Medicine (Infectious Diseases), University of Utah, Salt Lake City, United States
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Mbaga M, Msuya D, Mboma L, Jani B, Michael F, Kamugisha C, Said SA, Saleh A, Mwenda J, Cortese M. Intussusception among infants in Tanzania: findings from prospective hospital-based surveillance, 2013-2016. Pan Afr Med J 2021; 39:4. [PMID: 34548896 PMCID: PMC8437428 DOI: 10.11604/pamj.supp.2021.39.1.21358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/13/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction intussusception surveillance was initiated in Tanzania in 2013 after monovalent rotavirus vaccine was introduced, as part of the 7-country African evaluation to assess whether the vaccine was associated with an increased risk of intussusception. An increased risk from vaccine was not identified. Published data on intussusception in Tanzanian infants are limited. Methods prospective intussusception surveillance was conducted at 7 referral hospitals during 2013-2016 to identify all infants with intussusception meeting Brighton Level 1 criteria. Demographic, household and clinical data were collected by hospital clinicians and analyzed. Results a total of 207 intussusception cases were identified. The median age of cases was 5.8 months and nearly three-quarters were aged 4-7 months. Median number of days from symptom onset to admission at treatment hospital was 3 (IQR 2-5). Seventy-eight percent (152/195) of cases had been admitted at another hospital before transfer to the treating hospital. Enema reduction was not available; all infants were treated surgically and 55% (114/207) had intestinal resection. The overall case-fatality rate was 30% (62/206). Compared with infants who survived, those who died had longer duration of symptoms before admission to treatment hospital (median 4 vs 3 days; p < 0.01), higher rate of intestinal resection (81% [60/82] vs 44% [64/144], p < 0.001), and from families with lower incomes (i.e., less likely to own a television [p < 0.01] and refrigerator [p < 0.05). Conclusion Tanzanian infants who develop intussusception have a high case-fatality rate. Raising the index of suspicion among healthcare providers, allocating resources to allow wider availability of abdominal ultrasound for earlier diagnosis, and training teams in ultrasound-guided enema reduction techniques used in other African countries could reduce the fatality rate.
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Affiliation(s)
- Mwajabu Mbaga
- Muhimbili National Hospital, Dar Es Salaam, United Republic of Tanzania
| | - David Msuya
- Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Lazaro Mboma
- Mbeya Zonal Referral Hospital, Mbeya, United Republic of Tanzania
| | - Bhavin Jani
- World Health Organization, Country Office, Dar Es Salaam, United Republic of Tanzania
| | - Fausta Michael
- Ministry of Health, Community Development, Gender, Elderly and Children, Dar Es Salaam, United Republic of Tanzania
| | - Christopher Kamugisha
- World Health Organization, Country Office, Dar Es Salaam, United Republic of Tanzania
| | - Said Ali Said
- Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania
| | - Abdulhamid Saleh
- Immunization Program, Ministry of Health, Zanzibar, United Republic of Tanzania
| | - Jason Mwenda
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Margaret Cortese
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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9
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Arnold SLM. Target Product Profile and Development Path for Shigellosis Treatment with Antibacterials. ACS Infect Dis 2021; 7:948-958. [PMID: 33689318 DOI: 10.1021/acsinfecdis.0c00889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Enteric infection with Shigella spp. can lead to symptoms ranging from acute watery diarrhea to sudden, severe dysentery. Approximately 212 000 diarrheal deaths annually are attributed to Shigella with a disproportionate impact in low-resource countries. The impact in under-resourced countries was illustrated by a reanalysis of the Global Enteric Multicenter Study which found that Shigella was the leading pathogen associated with moderate-to severe diarrhea in children under 5 years old. While recent studies have highlighted the burden of the disease, there has been a concurrent reduction in therapeutic options for the treatment of shigellosis as drug resistant strains increase in prevalence. In addition, increasing reports of drug resistant shigellosis cases in the men who have sex with men community confirm that the impact is not limited to low-resource countries. Despite the urgent need for new treatments, a target product profile (TPP) has not been established, and there is no clear development path for antibacterial treatments. To address this troubling concern, this manuscript describes a TPP for antishigellosis small molecule therapeutics and a development path that integrates currently available preclinical and clinical models of Shigella infection.
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Affiliation(s)
- Samuel L. M. Arnold
- Division of Allergy and Infectious Diseases, Center for Emerging and Re-emerging Infectious Diseases, University of Washington School of Medicine, Seattle, Washington 98109, United States
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10
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Garbern SC, Chu TC, Gainey M, Kanekar SS, Nasrin S, Qu K, Barry MA, Nelson EJ, Leung DT, Schmid CH, Alam NH, Levine AC. Multidrug-resistant enteric pathogens in older children and adults with diarrhea in Bangladesh: epidemiology and risk factors. Trop Med Health 2021; 49:34. [PMID: 33966631 PMCID: PMC8108363 DOI: 10.1186/s41182-021-00327-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a global public health threat and is increasingly prevalent among enteric pathogens in low- and middle-income countries (LMICs). However, the burden of multidrug-resistant organisms (MDROs) in older children, adults, and elderly patients with acute diarrhea in LMICs is poorly understood. This study's aim was to characterize the prevalence of MDR enteric pathogens isolated from patients with acute diarrhea in Dhaka, Bangladesh, and assess a wide range of risk factors associated with MDR. METHODS This study was a secondary analysis of data collected from children over 5 years, adults, and elderly patients with acute diarrhea at the International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Hospital between March 2019 and March 2020. Clinical, historical, socio-environmental information, and a stool sample for culture and antimicrobial susceptibility testing were collected from each patient. Univariate statistics and multiple logistic regression were used to assess the prevalence of MDR among enteric pathogens and the association between independent variables and presence of MRDOs among culture-positive patients. RESULTS A total of 1198 patients had pathogens isolated by stool culture with antimicrobial susceptibility results. Among culture-positive patients, the prevalence of MDR was 54.3%. The prevalence of MDR was highest in Aeromonas spp. (81.5%), followed by Campylobacter spp. (72.1%), Vibrio cholerae (28.1%), Shigella spp. (26.2%), and Salmonella spp. (5.2%). Factors associated with having MDRO in multiple logistic regression included longer transport time to hospital (>90 min), greater stool frequency, prior antibiotic use prior to hospital presentation, and non-flush toilet use. However, pseudo-R2 was low 0.086, indicating that other unmeasured variables need to be considered to build a more robust predictive model of MDR. CONCLUSIONS MDR enteric pathogens were common in this study population with clinical, historical, and socio-environmental risk factors associated with MDROs. These findings may help guide clinical decision-making regarding antibiotic use and selection in patients at greatest risk of complications due to MDROs. Further prospective research is urgently needed to determine what additional factors place patients at greatest risk of MDRO, and the best strategies to mitigate the spread of MDR in enteric pathogens.
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Affiliation(s)
- Stephanie C Garbern
- Department of Emergency Medicine, Alpert Medical School, Brown University, 55 Claverick, 2nd Floor, Providence, RI, 02903, USA.
| | - Tzu-Chun Chu
- Center for Statistical Sciences, Brown University, 121 South Main Street, Providence, RI, 02903, USA
| | - Monique Gainey
- Rhode Island Hospital, 593 Eddy St, Providence, RI, 02903, USA
| | | | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Ave, Dhaka, 1212, Bangladesh
| | - Kexin Qu
- Department of Biostatistics, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Meagan A Barry
- Department of Emergency Medicine, Alpert Medical School, Brown University, 55 Claverick, 2nd Floor, Providence, RI, 02903, USA
| | - Eric J Nelson
- Departments of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, 2055 Mowry Road, Gainesville, FL, 32610, USA
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, 30 N 1900 E, Room 4B319, Salt Lake City, UT, 84132, USA
| | - Christopher H Schmid
- Department of Biostatistics, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Ave, Dhaka, 1212, Bangladesh
| | - Adam C Levine
- Department of Emergency Medicine, Alpert Medical School, Brown University, 55 Claverick, 2nd Floor, Providence, RI, 02903, USA
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Yang XL, Bai J, Song ZX, Zhang J, Liang M. [Value of serum procalcitonin combined with soluble triggering receptor expressed on myeloid cells-1 in the differential diagnosis of bacterial and viral diarrhea in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:887-891. [PMID: 32800037 PMCID: PMC7441503 DOI: 10.7499/j.issn.1008-8830.2002191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 06/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To study the value of serum procalcitonin (PCT) combined with soluble triggering receptor expressed on myeloid cells-1 (STREM-1) in the differential diagnosis of bacterial diarrhea and viral diarrhea in children. METHODS A retrospective analysis was performed on the medical data of 73 children with bacterial infectious diarrhea (bacteria group) and 68 children with viral infectious diarrhea (virus group) who were treated from February 2018 to May 2019. The receiver operating characteristic (ROC) curve was used to analyze the diagnostic efficacy of serum PCT and STREM-1 for bacterial infectious diarrhea and viral infectious diarrhea. RESULTS Compared with the virus group, the bacteria group had significantly higher detection rates of fecal red blood cells (79% vs 43%, P<0.05) and pus (51% vs 19%, P<0.05), as well as significantly higher serum levels of PCT and STREM-1 (P<0.05). The ROC curve analysis showed that in the differential diagnosis of bacterial infectious diarrhea and viral infectious diarrhea, serum PCT had a cut-off value of 0.97 ng/mL and an area under the ROC curve (AUC) of 0.792, and STREM-1 had a cut-off value of 15.66 ng/mL and an AUC of 0.889. Serum PCT combined with STREM-1 had an AUC of 0.955, which was significantly higher than that of each index alone (P<0.05). CONCLUSIONS Children with bacterial diarrhea have increased serum levels of PCT and STREM-1 than those with viral diarrhea. Both serum PCT and STREM-1 can be used as the indices for the differential diagnosis of bacterial diarrhea and viral diarrhea in children, and the combined measurement of PCT and STREM-1 can improve the efficiency of differential diagnosis.
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Affiliation(s)
- Xue-Li Yang
- Department of Pediatrics, Nanchong Central Hospital, Second Clinical Medical College of North Sichuan Medical College, Nanchong, Sichuan 637000, China.
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A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol. Trials 2020; 21:71. [PMID: 31931848 PMCID: PMC6956478 DOI: 10.1186/s13063-019-3829-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention. METHODS ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment. DISCUSSION Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines. TRIAL REGISTRATION Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.
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Abstract
OBJECTIVES Private pharmacies are widely established in most low/middle-income countries (LMICs) including Nepal, and are often considered as a patient's first point of contact for seeking healthcare. The aim of this study was to investigate the pattern of antibiotic dispensing in private pharmacies through exit interviews with patients to review their medication information. DESIGN AND SETTING Cross-sectional study. Data collection was carried out in 60 days at 33 randomly selected private pharmacies in the Rupandehi district of Nepal. PARTICIPANTS Patients attending private pharmacies (n=1537). MAIN OUTCOME MEASURE The pattern of antibiotic prescribing and dispensing was investigated using WHO's core prescribing indicator, 'the percentage of patients prescribed an antibiotic'. Frequency distributions were presented based on patients' characteristics, sources of antibiotic, registration status of pharmacies and education of the pharmacist or drug retailer, and disease or condition. χ2 tests and regression analysis were applied to explore factors associated with the pattern of antibiotic dispensing. RESULTS Of patients attending private pharmacies, the proportion receiving at least one antibiotic (38.4%) was above the WHO recommended value (20.0%-26.8%). The most commonly dispensed antibiotics were cefixime (16.9%) and the third-generation cephalosporins (38.0%) class. High dispensing rates of antibiotics for selected conditions (eg, respiratory infections, diarrhoeal cases) appeared contrary to international recommendations. The percentage of antibiotic dispensed was highest for patients who obtained their medicines from unlicensed pharmacies (59.1%). Young people were more likely to receive antibiotics than other age groups. CONCLUSIONS The antibiotic dispensing pattern from private pharmacies in Nepal was high compared with WHO guidelines, suggesting initiatives to reduce inappropriate use of antibiotics should be implemented. The findings of this study may be generalisable to other LMICs in order to assist in developing policies and guidelines to promote more appropriate dispensing and prescribing practices of antibiotics and limit the spread of antibiotic resistance.
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Affiliation(s)
- Anant Nepal
- Executive Board, Nepal Karuna Sewa Samaj, Palpa, Nepal
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Delia Hendrie
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Suzanne Robinson
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Linda A Selvey
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
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Platts-Mills JA, Liu J, Rogawski ET, Kabir F, Lertsethtakarn P, Siguas M, Khan SS, Praharaj I, Murei A, Nshama R, Mujaga B, Havt A, Maciel IA, McMurry TL, Operario DJ, Taniuchi M, Gratz J, Stroup SE, Roberts JH, Kalam A, Aziz F, Qureshi S, Islam MO, Sakpaisal P, Silapong S, Yori PP, Rajendiran R, Benny B, McGrath M, McCormick BJJ, Seidman JC, Lang D, Gottlieb M, Guerrant RL, Lima AAM, Leite JP, Samie A, Bessong PO, Page N, Bodhidatta L, Mason C, Shrestha S, Kiwelu I, Mduma ER, Iqbal NT, Bhutta ZA, Ahmed T, Haque R, Kang G, Kosek MN, Houpt ER. Use of quantitative molecular diagnostic methods to assess the aetiology, burden, and clinical characteristics of diarrhoea in children in low-resource settings: a reanalysis of the MAL-ED cohort study. LANCET GLOBAL HEALTH 2018; 6:e1309-e1318. [PMID: 30287127 PMCID: PMC6227251 DOI: 10.1016/s2214-109x(18)30349-8] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/28/2018] [Accepted: 07/11/2018] [Indexed: 12/17/2022]
Abstract
Background Optimum management of childhood diarrhoea in low-resource settings has been hampered by insufficient data on aetiology, burden, and associated clinical characteristics. We used quantitative diagnostic methods to reassess and refine estimates of diarrhoea aetiology from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study. Methods We re-analysed stool specimens from the multisite MAL-ED cohort study of children aged 0–2 years done at eight locations (Dhaka, Bangladesh; Vellore, India; Bhaktapur, Nepal; Naushero Feroze, Pakistan; Venda, South Africa; Haydom, Tanzania; Fortaleza, Brazil; and Loreto, Peru), which included active surveillance for diarrhoea and routine non-diarrhoeal stool collection. We used quantitative PCR to test for 29 enteropathogens, calculated population-level pathogen-specific attributable burdens, derived stringent quantitative cutoffs to identify aetiology for individual episodes, and created aetiology prediction scores using clinical characteristics. Findings We analysed 6625 diarrhoeal and 30 968 non-diarrhoeal surveillance stools from 1715 children. Overall, 64·9% of diarrhoea episodes (95% CI 62·6–71·2) could be attributed to an aetiology by quantitative PCR compared with 32·8% (30·8–38·7) using the original study microbiology. Viral diarrhoea (36·4% of overall incidence, 95% CI 33·6–39·5) was more common than bacterial (25·0%, 23·4–28·4) and parasitic diarrhoea (3·5%, 3·0–5·2). Ten pathogens accounted for 95·7% of attributable diarrhoea: Shigella (26·1 attributable episodes per 100 child-years, 95% CI 23·8–29·9), sapovirus (22·8, 18·9–27·5), rotavirus (20·7, 18·8–23·0), adenovirus 40/41 (19·0, 16·8–23·0), enterotoxigenic Escherichia coli (18·8, 16·5–23·8), norovirus (15·4, 13·5–20·1), astrovirus (15·0, 12·0–19·5), Campylobacter jejuni or C coli (12·1, 8·5–17·2), Cryptosporidium (5·8, 4·3–8·3), and typical enteropathogenic E coli (5·4, 2·8–9·3). 86·2% of the attributable incidence for Shigella was non-dysenteric. A prediction score for shigellosis was more accurate (sensitivity 50·4% [95% CI 46·7–54·1], specificity 84·0% [83·0–84·9]) than current guidelines, which recommend treatment only of bloody diarrhoea to cover Shigella (sensitivity 14·5% [95% CI 12·1–17·3], specificity 96·5% [96·0–97·0]). Interpretation Quantitative molecular diagnostics improved estimates of pathogen-specific burdens of childhood diarrhoea in the community setting. Viral causes predominated, including a substantial burden of sapovirus; however, Shigella had the highest overall burden with a high incidence in the second year of life. These data could improve the management of diarrhoea in these low-resource settings. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Elizabeth T Rogawski
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Shaila S Khan
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | | | | | - Buliga Mujaga
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | | | | | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Darwin J Operario
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Suzanne E Stroup
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - James H Roberts
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - M Ohedul Islam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Pimmada Sakpaisal
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Sasikorn Silapong
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Pablo P Yori
- Asociación Benéfica PRISMA, Iquitos, Peru; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Monica McGrath
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Jessica C Seidman
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Dennis Lang
- Foundation for the National Institutes of Health, Bethesda, MD, USA
| | - Michael Gottlieb
- Foundation for the National Institutes of Health, Bethesda, MD, USA
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Nicola Page
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Ladaporn Bodhidatta
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Carl Mason
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | - Sanjaya Shrestha
- Walter Reed/AFRIMS Research Unit, Nepal, Kathmandu, Nepal; University of Bergen, Bergen, Norway
| | - Ireen Kiwelu
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | | | | | | | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Margaret N Kosek
- Asociación Benéfica PRISMA, Iquitos, Peru; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
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Schnee AE, Haque R, Taniuchi M, Uddin MJ, Alam MM, Liu J, Rogawski ET, Kirkpatrick B, Houpt ER, Petri WA, Platts-Mills JA. Identification of Etiology-Specific Diarrhea Associated With Linear Growth Faltering in Bangladeshi Infants. Am J Epidemiol 2018; 187:2210-2218. [PMID: 29767678 PMCID: PMC6166216 DOI: 10.1093/aje/kwy106] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 05/08/2018] [Indexed: 01/02/2023] Open
Abstract
Childhood diarrhea in low-resource settings has been variably linked to linear growth shortfalls. However, the association between etiology-specific diarrhea and growth has not been comprehensively evaluated. We tested diarrheal stools collected from the Performance of Rotavirus and Oral Polio Vaccines in Developing Countries study from 2011 to 2013 in Dhaka, Bangladesh, by quantitative polymerase chain reaction for a broad range of enteropathogens to characterize diarrhea etiology and examine the association between etiology-specific diarrhea and linear growth and systemic inflammation. Pathogen-specific burdens of diarrhea were determined using attributable fractions. Linear regression was used to examine associations of pathogen-specific diarrhea with length-for-age z scores (LAZ) and serum C-reactive protein. There was no relationship between all-cause diarrhea and length at 12 months (change in 12-month LAZ per episode, −0.01, 95% confidence interval (CI): −0.06, 0.03). However, Cryptosporidium (change in 12-month LAZ per attributable episode, −0.23, 95% CI: −0.50, 0.03), Campylobacter jejuni/coli (change of −0.16, 95% CI: −0.32, −0.01), and Shigella/enteroinvasive Escherichia coli diarrhea (change of −0.12, 95% CI: −0.26, 0.03) were associated with linear growth deficits. Diarrhea attributable to C. jejuni/coli and Shigella/enteroinvasive E. coli were associated with elevated C-reactive protein. The association between diarrhea and linear growth appears to be pathogen-specific, reinforcing the need for pathogen-specific interventions.
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Affiliation(s)
- Amanda E Schnee
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Md Jashim Uddin
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Md Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jie Liu
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Elizabeth T Rogawski
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Beth Kirkpatrick
- Department of Medicine and Vaccine Testing Center, College of Medicine, University of Vermont, Burlington, VT
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - William A Petri
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, School of Medicine, University of Virginia, Charlottesville, Virginia
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Pavlinac PB, Brander RL, Atlas HE, John-Stewart GC, Denno DM, Walson JL. Interventions to reduce post-acute consequences of diarrheal disease in children: a systematic review. BMC Public Health 2018; 18:208. [PMID: 29391004 PMCID: PMC5796301 DOI: 10.1186/s12889-018-5092-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/17/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Although acute diarrhea often leads to acute dehydration and electrolyte imbalance, children with diarrhea also suffer long term morbidity, including recurrent or prolonged diarrhea, loss of weight, and linear growth faltering. They are also at increased risk of post-acute mortality. The objective of this systematic review was to identify interventions that address these longer term consequences of diarrhea. METHODS We searched Medline for randomized controlled trials (RCTs) of interventions conducted in low- and middle-income countries, published between 1980 and 2016 that included children under 15 years of age with diarrhea and follow-up of at least 7 days. Effect measures were summarized by intervention. PRISMA guidelines were followed. RESULTS Among 314 otherwise eligible RCTs, 65% were excluded because follow-up did not extend beyond 7 days. Forty-six trials were included, the majority of which (59%) were conducted in Southeast Asia (41% in Bangladesh alone). Most studies were small, 76% included less than 200 participants. Interventions included: therapeutic zinc alone (28.3%) or in combination with vitamin A (4.3%), high protein diets (19.6%), probiotics (10.9%), lactose free diets (10.9%), oral rehydration solution (ORS) formulations (8.7%), dietary supplements (6.5%), other dietary interventions (6.5%), and antimicrobials (4.3%). Prolonged or recurrent diarrhea was the most commonly reported outcome, and was assessed in ORS, probiotic, vitamin A, and zinc trials with no consistent benefit observed. Seven trials evaluated mortality, with follow-up times ranging from 8 days to 2 years. Only a single trial found a mortality benefit (therapeutic zinc). There were mixed results for dietary interventions affecting growth and diarrhea outcomes in the post-acute period. CONCLUSION Despite the significant post-acute mortality and morbidity associated with diarrheal episodes, there is sparse evidence evaluating the effects of interventions to decrease these sequelae. Adequately powered trials with extended follow-up are needed to identify effective interventions to prevent post-acute diarrhea outcomes.
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Affiliation(s)
| | | | - Hannah E. Atlas
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Department of Pediatrics, University of Washington, Seattle, WA USA
- Department of Medicine (Infectious Disease), University of Washington, Seattle, WA USA
| | - Donna M. Denno
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Pediatrics, University of Washington, Seattle, WA USA
- Department of Health Services, University of Washington, Seattle, WA USA
| | - Judd L. Walson
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Department of Pediatrics, University of Washington, Seattle, WA USA
- Department of Medicine (Infectious Disease), University of Washington, Seattle, WA USA
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Toda M, Zurovac D, Njeru I, Kareko D, Mwau M, Morita K. Health worker knowledge of Integrated Disease Surveillance and Response standard case definitions: a cross-sectional survey at rural health facilities in Kenya. BMC Public Health 2018; 18:146. [PMID: 29343225 PMCID: PMC5772726 DOI: 10.1186/s12889-018-5028-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 01/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The correct knowledge of standard case definition is necessary for frontline health workers to diagnose suspected diseases across Africa. However, surveillance evaluations commonly assume this prerequisite. This study assessed the knowledge of case definitions for health workers and their supervisors for disease surveillance activities in rural Kenya. METHODS A cross-sectional survey including 131 health workers and their 11 supervisors was undertaken in two counties in Kenya. Descriptive analysis was conducted to classify the correctness of knowledge into four categories for three tracer diseases (dysentery, measles, and dengue). We conducted a univariate and multivariable logistic regression analyses to explore factors influencing knowledge of the case definition for dysentery. RESULTS Among supervisors, 81.8% knew the correct definition for dysentery, 27.3% for measles, and no correct responses were provided for dengue. Correct knowledge was observed for 50.4% of the health workers for dysentery, only 12.2% for measles, and none for dengue. Of 10 examined factors, the following were significantly associated with health workers' correct knowledge of the case definition for dysentery: health workers' cadre (aOR 2.71; 95% CI 1.20-6.12; p = 0.017), and display of case definition poster (aOR 2.24; 95% CI 1.01-4.98; p = 0.048). Health workers' exposure to the surveillance refresher training, supportive supervision and guidelines were not significantly associated with the knowledge. CONCLUSION The correct knowledge of standard case definitions was sub-optimal among health workers and their supervisors, which is likely to impact the reliability of routine surveillance reports generated from health facilities.
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Affiliation(s)
- Mitsuru Toda
- Nagasaki University Institute of Tropical Medicine, KEMRI-NUITM, Kenyatta Hospital Grounds, Nairobi, Kenya.
| | - Dejan Zurovac
- Oxford University, Oxford, UK.,Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ian Njeru
- Kenya Ministry of Health Disease Surveillance and Response Unit, Nairobi, Kenya
| | - David Kareko
- Kenya Ministry of Health Disease Surveillance and Response Unit, Nairobi, Kenya
| | - Matilu Mwau
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Kouichi Morita
- Nagasaki University Institute of Tropical Medicine, Nagasaki, Japan
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Mokomane M, Kasvosve I, de Melo E, Pernica JM, Goldfarb DM. The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management. Ther Adv Infect Dis 2018; 5:29-43. [PMID: 29344358 PMCID: PMC5761924 DOI: 10.1177/2049936117744429] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Acute diarrhoeal diseases remain a leading cause of global morbidity and mortality particularly among young children in resource-limited countries. Recent large studies utilizing case-control design, prospective sampling and more sensitive and broad diagnostic techniques have shed light on particular pathogens of importance and highlighted the previously under recognized impact of these infections on post-acute illness mortality and growth. Vaccination, particularly against rotavirus, has emerged as a key effective means of preventing significant morbidity and mortality from childhood diarrhoeal disease. Other candidate vaccines against leading diarrhoeal pathogens, such as enterotoxigenic Escherichia coli and Shigella spp., also hold significant promise in further ameliorating the burden of enteric infections in children. Large studies are also currently underway evaluating novel and potential easy-to-implement water, sanitation and hygiene (WASH) preventive strategies. Given the ongoing global burden of this illness, the paucity of new advances in case management over the last several decades remains a challenge. The increasing recognition of post-acute illness mortality and growth impairment has highlighted the need for interventions that go beyond management of dehydration and electrolyte disturbances. The few trials of novel promising interventions such as probiotics have mainly been conducted in high-income settings. Trials of antimicrobials have also been primarily conducted in high-income settings or in travellers from high-income settings. Bloody diarrhoea has been shown to be a poor marker of potentially treatable bacterial enteritis, and rising antimicrobial resistance has also made empiric antimicrobial therapy more challenging in many settings. Novel effective and sustainable interventions and diagnostic strategies are clearly needed to help improve case management. Diarrhoeal disease and other enteric infections remain an unmet challenge in global child health. Most promising recent developments have been focused around preventive measures, in particular vaccination. Further advances in prevention and case management including the possible use of targeted antimicrobial treatment are also required to fully address this critical burden on child health and human potential.
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Affiliation(s)
- Margaret Mokomane
- Department of Medical Laboratory Science, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana; Botswana National Health Laboratory, Ministry of Health, Gaborone, Botswana
| | - Ishmael Kasvosve
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Emilia de Melo
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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Obiero CW, Ndiaye AGW, Sciré AS, Kaunyangi BM, Marchetti E, Gone AM, Schütte LD, Riccucci D, Auerbach J, Saul A, Martin LB, Bejon P, Njuguna P, Podda A. A Phase 2a Randomized Study to Evaluate the Safety and Immunogenicity of the 1790GAHB Generalized Modules for Membrane Antigen Vaccine against Shigella sonnei Administered Intramuscularly to Adults from a Shigellosis-Endemic Country. Front Immunol 2017; 8:1884. [PMID: 29375556 PMCID: PMC5763125 DOI: 10.3389/fimmu.2017.01884] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/11/2017] [Indexed: 01/08/2023] Open
Abstract
Shigellosis is a mild-to-severe diarrheal infection, caused by the genus Shigella, and is responsible for significant morbidity and mortality worldwide. We evaluated the safety and immunogenicity of an investigational Shigella sonnei vaccine (1790GAHB) based on generalized modules for membrane antigens (GMMA) in Kenya, a Shigella-endemic country. This phase 2a, observer-blind, controlled randomized study (NCT02676895) enrolled 74 healthy adults aged 18–45 years, of whom 72 were vaccinated. Participants received, in a 1:1:1 ratio, two vaccinations with the 1790GAHB vaccine at doses of either 1.5/25 μg of O antigen (OAg)/protein (group 1.5/25 μg) or 5.9/100 μg (group 5.9/100 μg) at day (D) 1 and D29, or vaccination with a quadrivalent meningococcal vaccine at D1 and tetanus, diphtheria, and acellular pertussis vaccine at D29 (control group). Solicited and unsolicited adverse events (AEs), serious AEs (SAEs), and AEs of special interest (neutropenia and reactive arthritis) were collected. Anti-S. sonnei lipopolysaccharide (LPS) serum immunoglobulin G (IgG) geometric mean concentrations (GMC) were evaluated at D1, D29, and D57 and compared to anti-S. sonnei LPS antibody levels in convalescent patients naturally exposed to S. sonnei. The percentages of participants with seroresponse were also calculated. The most frequently reported solicited local and systemic AEs across all groups were pain and headache, respectively. Only one case of severe systemic reaction was reported (severe headache after first vaccination in group 5.9/100 μg). Seven and three episodes of neutropenia, assessed as probably or possibly related to vaccination respectively, were reported in the investigational and control groups, respectively. No other SAEs were reported. Despite very high baseline anti-S. sonnei LPS serum IgG levels, the 1790GAHB vaccine induced robust antibody responses. At D29, GMC increased 2.10- and 4.43-fold from baseline in groups 1.5/25 and 5.9/100 μg, respectively, whereas no increase was observed in the control group. Antibody titers at D57 were not statistically different from those at D29. Seroresponse was 68% at D29 and 90% at D57 in group 1.5/25 μg, and 96% after each vaccination in group 5.9/100 μg. The 1790GAHB vaccine was well tolerated and highly immunogenic in a population of African adults, regardless of the GMMA OAg/protein content used.
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Affiliation(s)
- Christina W Obiero
- KEMRI-Wellcome Trust Research Programme, Clinical Research Department, Kilifi, Kenya
| | | | | | - Bonface M Kaunyangi
- KEMRI-Wellcome Trust Research Programme, Clinical Research Department, Kilifi, Kenya
| | | | - Ann M Gone
- KEMRI-Wellcome Trust Research Programme, Clinical Research Department, Kilifi, Kenya
| | | | | | | | - Allan Saul
- GSK Vaccines Institute for Global Health, Siena, Italy
| | | | - Philip Bejon
- Clinical Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Headington, United Kingdom
| | - Patricia Njuguna
- KEMRI-Wellcome Trust Research Programme, Clinical Research Department, Kilifi, Kenya.,Department of Public Health, Pwani University, Kilifi, Kenya
| | - Audino Podda
- GSK Vaccines Institute for Global Health, Siena, Italy
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Tickell KD, Brander RL, Atlas HE, Pernica JM, Walson JL, Pavlinac PB. Identification and management of Shigella infection in children with diarrhoea: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e1235-e1248. [PMID: 29132613 PMCID: PMC5695759 DOI: 10.1016/s2214-109x(17)30392-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 08/22/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Shigella infections are a leading cause of diarrhoeal death among children in low-income and middle-income countries. WHO guidelines reserve antibiotics for treating children with dysentery. Reliance on dysentery for identification and management of Shigella infection might miss an opportunity to reduce Shigella-associated morbidity and mortality. We aimed to systematically review and evaluate Shigella-associated and dysentery-associated mortality, the diagnostic value of dysentery for the identification of Shigella infection, and the efficacy of antibiotics for children with Shigella or dysentery, or both. METHODS We did three systematic reviews (for mortality, diagnostic value, and antibiotic treatment of Shigella and dysentery), and meta-analyses where appropriate, of studies in resource-limited settings. We searched MEDLINE, Embase, and LILACS database for studies published before Jan 1, 2017, in English, French, and Spanish. We included studies of human beings with diarrhoea and accepted all study-specific definitions of dysentery. For the mortality and diagnostic value searches, we excluded studies that did not include an effect estimate or data necessary to calculate this estimate. The search for treatment included only randomised controlled trials that were done after Jan 1, 1980, and assessed antibiotics in children (aged <18 years) with dysentery or laboratory-confirmed Shigella. We extracted or calculated odds ratios (ORs) and 95% CIs for relative mortality and did random-effects meta-analysis to arrive at pooled ORs. We calculated 95% CIs assuming a binomial distribution and did random-effects meta-regression of log-transformed sensitivity and specificity estimates for diagnostic value. We assessed the heterogeneity of papers included in these meta-analyses using the I2 statistic and evaluated publication bias using funnel plots. This review is registered with PROSPERO (CRD42017063896). FINDINGS 3649 papers were identified and 60 studies were included for analyses: 13 for mortality, 27 for diagnostic value, and 20 for treatment. Shigella infection was associated with mortality (pooled OR 2·8, 95% CI 1·6-4·8; p=0·000) whereas dysentery was not associated with mortality (1·3, 0·7-2·3; p=0·37). Between 1977 and 2016, dysentery identified 1·9-85·9% of confirmed Shigella infections, with sensitivity decreasing over time (p=0·04). Ten (50%) of 20 included antibiotic trials were among children with dysentery, none were placebo-controlled, and two (10%) evaluated antibiotics no longer recommended for acute infectious diarrhoea. Ciprofloxacin showed superior microbiological, but not clinical, effectiveness compared with pivmecillinam, and no superior microbiological and clinical effectiveness compared with gatifloxacin. Substantial heterogeneity was reported for meta-analyses of the Shigella-associated mortality studies (I2=78·3%) and dysentery-associated mortality studies (I2=73·2%). Too few mortality studies were identified to meaningfully test for publication bias. No evidence of publication bias was found in this analysis of studies of diagnostic value. INTERPRETATION Current WHO guidelines appear to manage dysentery effectively, but might miss opportunities to reduce mortality among children infected with Shigella who present without bloody stool. Further studies should quantify potential decreases in mortality and morbidity associated with antibiotic therapy for children with non-dysenteric Shigella infection. FUNDING Bill & Melinda Gates Foundation and the Center for AIDS Research International Core.
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Affiliation(s)
- Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Rebecca L Brander
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Hannah E Atlas
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jeffrey M Pernica
- Division of Infectious Disease, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
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Tickell KD, Pavlinac PB, John-Stewart GC, Denno DM, Richardson BA, Naulikha JM, Kirera RK, Swierczewski BE, Singa BO, Walson JL. Impact of Childhood Nutritional Status on Pathogen Prevalence and Severity of Acute Diarrhea. Am J Trop Med Hyg 2017; 97:1337-1344. [PMID: 29140236 PMCID: PMC5817755 DOI: 10.4269/ajtmh.17-0139] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Children with acute and chronic malnutrition are at increased risk of morbidity and mortality following a diarrheal episode. To compare diarrheal disease severity and pathogen prevalence among children with and without acute and chronic malnutrition, we conducted a cross-sectional study of human immunodeficiency virus-uninfected Kenyan children aged 6–59 months, who presented with acute diarrhea. Children underwent clinical and anthropometric assessments and provided stool for bacterial and protozoal pathogen detection. Clinical and microbiological features were compared using log binomial regression among children with and without wasting (mid-upper arm circumference ≤ 125 mm) or stunting (height-for-age z score ≤ −2). Among 1,363 children, 7.0% were wasted and 16.9% were stunted. After adjustment for potential confounders, children with wasting were more likely than nonwasted children to present with at least one Integrated Management of Childhood Illness danger sign (adjusted prevalence ratio [aPR]: 1.3, 95% confidence interval [CI]: 1.0 to 1.5, P = 0.05), severe dehydration (aPR: 2.4, 95% CI: 1.5 to 3.8, P < 0.01), and enteroaggregative Escherichia coli recovered from their stool (aPR: 1.8, 1.1–2.8, P = 0.02). There were no differences in the prevalence of other pathogens by wasting status after confounder adjustment. Stunting was not associated with clinical severity or the presence of specific pathogens. Wasted children with diarrhea presented with more severe disease than children without malnutrition which may be explained by a delay in care-seeking or diminished immune response to infection. Combating social determinants and host risk factors associated with severe disease, rather than specific pathogens, may reduce the disparities in poor diarrhea-associated outcomes experienced by malnourished children.
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Affiliation(s)
- Kirkby D Tickell
- University of Washington, Seattle, Washington.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | | | | | - Donna M Denno
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,University of Washington, Seattle, Washington
| | | | | | - Ronald K Kirera
- United States Army Medical Research Directorate-Kenya (USAMD-K), Nairobi, Kenya
| | | | - Benson O Singa
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,University of Washington, Seattle, Washington
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Pernica JM, Steenhoff AP, Mokomane M, Moorad B, Lechiile K, Smieja M, Mazhani L, Cheng J, Kelly MS, Loeb M, Stordal K, Goldfarb DM. Rapid enteric testing to permit targeted antimicrobial therapy, with and without Lactobacillus reuteri probiotics, for paediatric acute diarrhoeal disease in Botswana: A pilot, randomized, factorial, controlled trial. PLoS One 2017; 12:e0185177. [PMID: 28991918 PMCID: PMC5633142 DOI: 10.1371/journal.pone.0185177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/03/2017] [Indexed: 01/29/2023] Open
Abstract
Introduction Diarrhoeal disease is the second-leading cause of death in young children. Current guidelines recommend treating children with acute non-bloody diarrhea with oral rehydration solutions and zinc, but not antimicrobials. However, in many resource-limited settings, infections with treatable enteric bacterial and protozoan pathogens are common. Probiotics have shown promise as an adjunct treatment for diarrhoea but have not been studied in sub-Saharan Africa. Methods We conducted a pilot, factorial, randomized, placebo-controlled trial of children aged 2–60 months hospitalized in Botswana for acute non-bloody diarrhoea. A rapid test-and-treat intervention, consisting of multiplex PCR testing of rectal swabs taken at enrolment, accompanied by targeted antimicrobial therapy if treatable pathogens were detected, was compared to the reference standard of no stool testing. Additionally, Lactobacillus reuteri DSM 17938 x 60 days was compared to placebo treatment. The main objective of this pilot study was to assess feasibility. The primary clinical outcome was the increase in age-standardized height (HAZ) at 60 days adjusted for baseline HAZ. Results Seventy-six patients were enrolled over a seven-month study period. We judged that the recruitment rate, lab processing times, communication protocols, provision of specific antimicrobials, and follow-up rates were acceptable. Compared to the reference arm (no stool testing and placebo treatment), the combination of the rapid test-and-treat strategy plus L. reuteri DSM 17938 was associated with an increase of 0.61 HAZ (95% CI 0.09–1.13) and 93% lower odds of recurrent diarrhoea (OR 0.07, 95%CI 0.01–0.61) at 60 days. Discussion We demonstrated that it was feasible to evaluate the study interventions in Botswana. Despite the small sample size, we observed a statistically significant increase in HAZ at 60 days and significantly lower odds of recurrent diarrhoea in children receiving both rapid test-and-treat and L. reuteri. There is sufficient evidence to warrant proceeding with a larger follow-up trial in a similar setting.
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Affiliation(s)
- Jeffrey M. Pernica
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - Andrew P. Steenhoff
- Center for Global Health & Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Margaret Mokomane
- Botswana Ministry of Health, National Health Laboratory, Gaborone, Botswana
| | | | | | - Marek Smieja
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Loeto Mazhani
- Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Ji Cheng
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Matthew S. Kelly
- Department of Pediatrics, Duke University, Durham, North Carolina, United States of America
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - David M. Goldfarb
- Department of Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Multiplex molecular diagnostic tests and the management of diarrhea: the wave of the future? Curr Opin Infect Dis 2017; 30:471-472. [PMID: 28873080 DOI: 10.1097/qco.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Ninety-nine percent of the 5.9 million annual child deaths occur in low and middle-income countries. Undernutrition underlies 45% of deaths. Determinants include access to care, maternal education, and absolute and relative poverty. Socio-political-economic factors and policies tremendously influence health and their determinants. Most deaths can be prevented with interventions that are currently available and recommended for widespread implementation. Millennium Development Goal 4 was not achieved. Sustainable Development Goal 3.2 presents an even more ambitious target and opportunity to save millions of lives; and requires attention to scaling up interventions, especially among the poorest and most vulnerable children.
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Rogawski ET, Platts-Mills JA, Seidman JC, John S, Mahfuz M, Ulak M, Shrestha SK, Soofi SB, Yori PP, Mduma E, Svensen E, Ahmed T, Lima AA, Bhutta ZA, Kosek MN, Lang DR, Gottlieb M, Zaidi AK, Kang G, Bessong PO, Houpt ER, Guerrant RL. Use of antibiotics in children younger than two years in eight countries: a prospective cohort study. Bull World Health Organ 2016; 95:49-61. [PMID: 28053364 PMCID: PMC5180352 DOI: 10.2471/blt.16.176123] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/31/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To describe the frequency and factors associated with antibiotic use in early childhood, and estimate the proportion of diarrhoea and respiratory illnesses episodes treated with antibiotics. METHODS Between 2009 and 2014, we followed 2134 children from eight sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa and the United Republic of Tanzania, enrolled in the MAL-ED birth cohort study. We documented all antibiotic use from mothers' reports at twice-weekly visits over the children's first two years of life. We estimated the incidence of antibiotic use and the associations of antibiotic use with child and household characteristics. We described treatment patterns for diarrhoea and respiratory illnesses, and identified factors associated with treatment and antibiotic class. FINDINGS Over 1 346 388 total days of observation, 16 913 courses of antibiotics were recorded (an incidence of 4.9 courses per child per year), with the highest use in South Asia. Antibiotic treatment was given for 375/499 (75.2%) episodes of bloody diarrhoea and for 4274/9661 (44.2%) episodes of diarrhoea without bloody stools. Antibiotics were used in 2384/3943 (60.5%) episodes of fieldworker-confirmed acute lower respiratory tract illness as well as in 6608/16742 (39.5%) episodes of upper respiratory illness. Penicillins were used most frequently for respiratory illness, while antibiotic classes for diarrhoea treatment varied within and between sites. CONCLUSION Repeated antibiotic exposure was common early in life, and treatment of non-bloody diarrhoea and non-specific respiratory illnesses was not consistent with international recommendations. Rational antibiotic use programmes may have the most impact in South Asia, where antibiotic use was highest.
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Affiliation(s)
- Elizabeth T Rogawski
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
| | - Jessica C Seidman
- Fogarty International Center, National Institutes of Health, Bethesda, USA
| | | | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Manjeswori Ulak
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | | | - Estomih Mduma
- Haydom Lutheran Hospital, Haydom, United Republic of Tanzania
| | | | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Aldo Am Lima
- Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil
| | | | - Margaret N Kosek
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Dennis R Lang
- Foundation for the National Institutes of Health, Bethesda, USA
| | | | | | | | | | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801379, Carter Harrison Research Bldg MR-6, 345 Crispell Drive, Room 2520, Charlottesville, Virginia 22908-1379, United States of America (USA)
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