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. 2019 Feb 8;13(2):e0007154.
doi: 10.1371/journal.pntd.0007154. eCollection 2019 Feb.

Etiology and severity of diarrheal diseases in infants at the semiarid region of Brazil: A case-control study

Aldo A M Lima  1 , Domingos B Oliveira  1 , Josiane S Quetz  1 , Alexandre Havt  1 , Mara M G Prata  1 , Ila F N Lima  1 , Alberto M Soares  1 , José Q Filho  1 , Noélia L Lima  1 , Pedro H Q S Medeiros  1 , Ana K S Santos  1 , Herlice N Veras  1 , Rafhaella N D G Gondim  1 , Rafaela C Pankov  1 , Mariana D Bona  1 , Francisco A P Rodrigues  1 , Renato A Moreira  2 , Ana C O M Moreira  2 , Marcelo Bertolini  2 , Luciana R Bertolini  2 , Vicente J F Freitas  3 , Eric R Houpt  4 , Richard L Guerrant  1   4
Affiliations

Etiology and severity of diarrheal diseases in infants at the semiarid region of Brazil: A case-control study

Aldo A M Lima et al. PLoS Negl Trop Dis. .

Abstract

Background: Diarrheal diseases are an important cause of morbidity and mortality among children in developing countries. We aimed to study the etiology and severity of diarrhea in children living in the low-income semiarid region of Brazil.

Methodology: This is a cross-sectional, age-matched case-control study of diarrhea in children aged 2-36 months from six cities in Brazil's semiarid region. Clinical, epidemiological, and anthropometric data were matched with fecal samples collected for the identification of enteropathogens.

Results: We enrolled 1,200 children, 596 cases and 604 controls. By univariate analysis, eight enteropathogens were associated with diarrhea: Norovirus GII (OR 5.08, 95% CI 2.10, 12.30), Adenovirus (OR 3.79, 95% CI 1.41, 10.23), typical enteropathogenic Escherichia coli (tEPEC), (OR 3.28, 95% CI 1.39, 7.73), enterotoxigenic E. coli (ETEC LT and ST producing toxins), (OR 2.58, 95% CI 0.99, 6.69), rotavirus (OR 1.91, 95% CI 1.20, 3.02), shiga toxin-producing E. coli (STEC; OR 1.77, 95% CI 1.16, 2.69), enteroaggregative E. coli (EAEC), (OR 1.45, 95% CI 1.16, 1.83) and Giardia spp. (OR 1.39, 95% CI 1.05, 1.84). By logistic regression of all enteropathogens, the best predictors of diarrhea were norovirus, adenovirus, rotavirus, STEC, Giardia spp. and EAEC. A high diarrhea severity score was associated with EAEC.

Conclusions: Six enteropathogens: Norovirus, Adenovirus, Rotavirus, STEC, Giardia spp., and EAEC were associated with diarrhea in children from Brazil's semiarid region. EAEC was associated with increased diarrhea severity.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Location, participant enrollment and selection.
The semiarid region includes the states of Ceará, Piauí, Rio Grande do Norte, Paraíba, Pernambuco, Alagoas, Sergipe, and Bahia of the Northeastern macro-region, but does not include Maranhão and the area north of Minas Gerais (Fig 1). The semiarid region covers 969,589.4 km2 and has a population of 23.5 million. The estimated population of children under five years old is 2.3 million. The average annual rainfall is less than 800 mm and the aridity index can reach 0.5, which represents the water balance between precipitation and potential evapotranspiration. Drought risk in the semiarid region is greater than 60% [15].
Fig 2
Fig 2
Enteropathogens detected in diarrheal and non-diarrheal stools from children: A) 2–11 months, B) 12–23 months, and C) 24–36 months; pathogen prevalence by grouping: D) children with one, E) two, and F) three or more pathogens from the semiarid region in Brazil. EAEC = enteroaggregative E. coli; STEC = shiga toxin-producing E. coli; tEPEC = typical enteropathogenic E. coli; ST or LT ETEC = heat-stable or heat-labile producing enterotoxigenic E. coli.
Fig 3
Fig 3. Multivariate logistic regression analysis showing the attributable fraction of enteropathogens association with diarrheal stool samples.
See this image and copyright information in PMC

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