Risk Factors and Clinical Characteristics Associated with Enteropathogenic Escherichia coli Infection Among Children Less than Five Years Old with Moderate-to-Severe Diarrhea in Rural Western Kenya, 2008-2012 Open Access

Abstract

Background: Enteropathogenic Escherichia coli (EPEC) infection is a major cause of diarrhea and contributor to mortality in children <2 years old in developing countries. Limited data are available on risk factors for EPEC in children. The purpose of this study was to describe the prevalence of EPEC infections, assess the clinical characteristics of EPEC, and assess risk factors associated with EPEC among children <5 years old with moderate-to-severe diarrhea (MSD) enrolled in the Global Enteric Multicenter Study at the Kenyan study site.

Methods : MSD was defined as ≥3 loose stools in the previous 24 hours, with onset in the previous 7 days, and ≥1 of the following characteristics: loss of skin turgor, sunken eyes, dysentery, required IV rehydration, or hospitalization. Stool samples were tested at enrollment for presence of enteric pathogens. Demographic, clinical, anthropometric, and environmental data were collected at enrollment and at a ~60-day follow-up visit. Multivariable logistic regression was used to assess the risk factors and characteristics associated with typical EPEC and atypical EPEC. Multivariable linear regression was used to assess linear growth faltering.

Results: Of the 1778 cases enrolled in the study, 135 (7.6%) cases had typical EPEC, and 97 (5.5%) cases had atypical EPEC. 65% of typical EPEC, and 50% of atypical EPEC cases were infants (0-11 months old). 9.2% of typical EPEC cases, and 4.2% of atypical EPEC cases died prior to the 60-day follow-up visit. Clinical characteristics associated with typical EPEC included loss of skin turgor (adjusted odds ratio [aOR] 2.86, 95%CI: 1.08-4.82) and convulsions (aOR 2.95, 95%CI: 1.17-7.45). Infant cases with typical EPEC compared to those without were associated with linear growth faltering (p=0.002) between enrollment and follow-up. Clinical characteristics associated with atypical EPEC included difficulty breathing (aOR 3.35, 95%CI: 1.38-8.14) and coughing (aOR 1.93, 95%CI: 1.13-3.30). No environmental factors assessed were found to be associated with EPEC infection.

Discussion: Typical EPEC is a significant contributor to morbidity and mortality among infants with MSD in rural Kenya, while the pathogenicity of atypical EPEC remains unclear. Interventions aimed at reducing the burden of EPEC and its sequelae should be urgently investigated, prioritized, and implemented.

Table of Contents

INTRODUCTION.........................................................................................1

Background................................................................................................1

Significance................................................................................................2

LITERATURE REVIEW.................................................................................3

Enteropathogenic Escherichia coli (EPEC) Characteristics, Transmission, and Reservoirs..3

Clinical Characteristics of EPEC Infection in Children Under 5 Years Old.........4

Age............................................................................................................4

Malnutrition...............................................................................................5

HIV Status..................................................................................................6

EPEC Infection and Childhood Mortality.......................................................6

Known Risk Factors for EPEC in Developing Countries...................................7

Prevalence of Atypical EPEC & Typical EPEC in Industrialized and Developing Countries...7

EPEC in Kenya............................................................................................8

Diagnostic Techniques for Atypical EPEC and Typical EPEC...........................9

METHODOLGY..........................................................................................10

The Global Enteric Multicenter Study (GEMS): Overview and Enrollment......10

Study Site.................................................................................................12

Enteropathogenic Escherichia coli Identification.........................................12

Anthropometry.........................................................................................13

HIV..........................................................................................................13

Breastfeeding............................................................................................14

Definitions................................................................................................14

Statistical Analysis....................................................................................16

Ethical Review...........................................................................................17

RESULTS...................................................................................................18

Demographic and Household Characteristics...............................................19

Clinical Characteristics Presented in EPEC..................................................20

Breastfeeding............................................................................................22

HIV Status................................................................................................23

Enteric Co-infections.................................................................................24

60-Day Follow-Up.....................................................................................24

Anthropometric Measurements as Indicators of Malnutrition.......................25

Environmental Characteristics...................................................................26

DISCUSSION.............................................................................................28

Age...........................................................................................................28

Clinical Characteristics Associated with EPEC..............................................29

Hospitalizations and Mortality in Children with EPEC..................................29

EPEC Prevalence and HIV Status.................................................................30

Co-infection and EPEC...............................................................................31

Malnutrition Associated with EPEC.............................................................31

Environmental Risk Factors Associated with EPEC.......................................32

Limitations...............................................................................................33

CONCLUSION............................................................................................34

REFERENCES.............................................................................................36

FIGURE 1...................................................................................................41

FIGURE 2...................................................................................................41

TABLE 1.....................................................................................................42

TABLE 2.....................................................................................................43

TABLE 3.....................................................................................................45

TABLE 4.....................................................................................................45

TABLE 5.....................................................................................................46

TABLE 6.....................................................................................................47

TABLE 7.....................................................................................................47

TABLE 8.....................................................................................................48

APPENDIX I...............................................................................................50

About this Master's Thesis

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School	Rollins School of Public Health
Department	Environmental Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Environmental Health
Keyword	diarrhea infantile diarrhea atypical EPEC EPEC typical EPEC pathogenic Escherichia coli
Committee Chair / Thesis Advisor	Levy, Karen, Emory University
Committee Members	Tolbert, Paige, Emory University O'Reilly, Ciara, Centers for Disease Control and Prevention
Partnering Agencies	CDC

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