SummaryBackgroundEnteropathogen infections in early childhood not only cause diarrhoea but contribute to poor growth. We used molecular diagnostics to assess whether particular enteropathogens were associated with linear growth across seven low-resource settings.MethodsWe used quantitative PCR to detect 29 enteropathogens in diarrhoeal and non-diarrhoeal stools collected from children in the first 2 years of life obtained during the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) multisite cohort study. Length was measured monthly. We estimated associations between aetiology-specific diarrhoea and subclinical enteropathogen infection and quantity and attained length in 3 month intervals, at age 2 and 5 years, and used a longitudinal model to account for temporality and time-dependent confounding.FindingsAmong 1469 children who completed 2 year follow-up, 35 622 stool samples were tested and yielded valid results. Diarrhoeal episodes attributed to bacteria and parasites, but not viruses, were associated with small decreases in length after 3 months and at age 2 years. Substantial decrements in length at 2 years were associated with subclinical, non-diarrhoeal, infection with Shigella (length-for-age Z score [LAZ] reduction −0·14, 95% CI −0·27 to −0·01), enteroaggregative Escherichia coli (−0·21, −0·37 to −0·05), Campylobacter (−0·17, −0·32 to −0·01), and Giardia (−0·17, −0·30 to −0·05). Norovirus, Cryptosporidium, typical enteropathogenic E coli, and Enterocytozoon bieneusi were also associated with small decrements in LAZ. Shigella and E bieneusi were associated with the largest decreases in LAZ per log increase in quantity per g of stool (−0·13 LAZ, 95% CI −0·22 to −0·03 for Shigella; −0·14, −0·26 to −0·02 for E bieneusi). Based on these models, interventions that successfully decrease exposure to Shigella, enteroaggregative E coli, Campylobacter, and Giardia could increase mean length of children by 0·12–0·37 LAZ (0·4–1·2 cm) at the MAL-ED sites.InterpretationSubclinical infection and quantity of pathogens, particularly Shigella, enteroaggregative E coli, Campylobacter, and Giardia, had a substantial negative association with linear growth, which was sustained during the first 2 years of life, and in some cases, to 5 years. Successfully reducing exposure to certain pathogens might reduce global stunting.FundingBill & Melinda Gates Foundation.

SummaryBackgroundOptimum 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.MethodsWe 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.FindingsWe 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]).InterpretationQuantitative 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.FundingBill & Melinda Gates Foundation.

HighlightsChildren living in these settings had a high prevalence of enteropathogens, high levels of intestinal inflammation, abnormal intestinal permeability, high markers of systemic inflammation, and postnatal acquired linear growth deficits when compared to children living in the US or EuropeThis study contributes empiric evidence to demonstrate that enteric infection alters both fecal markers of inflammation and permeabilityCurrent markers of enteropathy fail to account for a large portion of the observed shortfalls in linear growth in these populations, and markers of systemic inflammation appear as the most promising predictive biomarkers for identifying linear growth failure in childrenEnvironmental enteropathy (EE) is hypothesized as a mediator of growth faltering, but few prospective studies have evaluated pathways linking enteropathogen exposure, intestinal inflammation and permeability, and growth. The MAL-ED study represents a novel analytical framework and explicitly evaluates multiple putative EE pathways in combination and using an unprecedented quantity of data. Despite evidence that gut inflammation and altered gut permeability are frequently present and that associations between enteropathogen exposure and gut dysfunction exist, the observed attributable effects of EE on growth faltering in young children were small.

No abstract

Specific classes of fecal bacteria are lower during episodes of acute diarrhea in children than during periods of normal gastrointestinal health, suggesting specific alterations in the flora during diarrhea.

An outbreak of acute diarrhoeal disease in a village in southern India was investigated through personal interviews of all households. Maps were drawn using geographic information system (GIS) tools of the water supply system, sewage channels and areas with observed faecal contamination of soil within and around the village. Geographic coordinates for each house in the village were extracted from a central database from the healthcare service provider for the village. Geographical clustering of cases was looked for using the SaTScan software, and diarrhoeal disease attack rates were calculated. Diarrhoeal disease occurred uniformly throughout the village without clustering in any area. All ages and both sexes were affected, but extremes of ages were at higher risk. Water samples collected for microbiological examination after instituting control measures showed high coliform counts. Chlorine levels in the water tested were found to be inadequate to decontaminate common pathogens. Local cultural practices such as indiscriminate defecation in public places, washing clothes and cleaning utensils from water taps where the community collected its drinking water, and poor engineering design and maintenance of the water supply system were the risk factors that could have contributed to this outbreak.

Neurocysticercosis (NCC) is a major cause of seizures/epilepsy in countries endemic for the disease. The objectives of this study were to spatially map the burden of active epilepsy (AE), NCC, taeniasis, seroprevalence for cysticercal antibodies and positivity to circulating cysticercal antigens in Kaniyambadi block (approximately 100 villages comprising 100 000 population) of Vellore district and to detect spatial clusters of AE, NCC, taeniasis and seroprevalence. Using geographic information system (GIS) techniques, all 21 study villages with over 8000 houses (population of 38 105) were mapped. Clustering of different indices of Taenia solium infection was determined using a spatial scan statistic (SaTScan). There was a primary spatial cluster of AE with a log likelihood ratio (LLR) of 10.8 and relative risk (RR) of 22.4; however, no significant clustering for NCC was detected. Five significant spatial clusters of seropositivity for cysticercal antibodies, two clusters of seropositivity for cysticercal antigens and one for taeniasis were detected (LLR of 8.35 and RR of 36.67). Our study has demonstrated the use of GIS methods in mapping and identifying 'hot spots' of various indices of T. solium infection in humans. This spatial analysis has identified pockets with high transmission rates so that preventive measures could be focused on an intensive scale.

We evaluated the exposure of a community in Vellore district of south India to Taenia solium infection and its relationship to the prevalence of neurocysticercosis (NCC) causing active epilepsy. Seroprevalence of Taenia cysticercus antigens and antibodies were determined in 1064 randomly chosen asymptomatic individuals, antibodies to T. solium ova in 197 selected sera, and prevalence of taeniasis by a coproantigen test in 729 stool samples. The prevalence of NCC causing active epilepsy in Vellore district was determined in a population of 50 617. Coproantigens were detected in 0.8% (6 samples), Taenia cysticercus antigens in 4.5% (48 sera) and cysticercus IgG antibodies in 15.9% (169 sera) of the population. Cysticercus antibodies were directed against relatively low molecular weight cyst glycoprotein antigens in 14.9% (158 sera) of the population. IgG antibodies to Taenia ova were found in 81 (41.1%) of the selected samples. Prevalence of NCC causing active epilepsy was 1.3 per 1000 population. These results show high exposure of the population to the parasite and a relatively high prevalence of active infections (4.5% antigen positives) but a low prevalence of NCC causing active epilepsy (0.13%). These findings may indicate that the population is protected against developing neurocysticercosis. IgG antibodies directed against Taenia ova and low molecular weight cyst antigens may contribute to protection.