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. 2024 Mar 22:12:1332319.
doi: 10.3389/fpubh.2024.1332319. eCollection 2024.

Epidemiology of enterotoxigenic Escherichia coli and impact on the growth of children in the first two years of life in Lima, Peru

Monica J Pajuelo  1 , Sassan Noazin  2 , Lilia Cabrera  3 , Angie Toledo  1 , Mirza Velagic  2 , Lucero Arias  1 , Mayra Ochoa  1 , Lawrence H Moulton  2 , Mayuko Saito  4 , Robert H Gilman  2 , Subhra Chakraborty  2
Affiliations

Epidemiology of enterotoxigenic Escherichia coli and impact on the growth of children in the first two years of life in Lima, Peru

Monica J Pajuelo et al. Front Public Health. .

Abstract

Background: Enterotoxigenic E. coli (ETEC) is a leading cause of diarrheal morbidity and mortality in children, although the data on disease burden, epidemiology, and impact on health at the community level are limited.

Methods: In a longitudinal birth cohort study of 345 children followed until 24 months of age in Lima, Peru, we measured ETEC burden in diarrheal and non-diarrheal samples using quantitative PCR (LT, STh, and STp toxin genes), studied epidemiology and measured anthropometry in children.

Results: About 70% of children suffered from one or more ETEC diarrhea episodes. Overall, the ETEC incidence rate (IR) was 73 per 100 child-years. ETEC infections began early after birth causing 10% (8.9-11.1) ETEC-attributable diarrheal burden at the population level (PAF) in neonates and most of the infections (58%) were attributed to ST-ETEC [PAF 7.9% (1.9-13.5)] and LT + ST-ETEC (29%) of which all the episodes were associated with diarrhea. ETEC infections increased with age, peaking at 17% PAF (4.6-27.7%; p = 0.026) at 21 to 24 months. ST-ETEC was the most prevalent type (IR 32.1) with frequent serial infections in a child. The common colonization factors in ETEC diarrhea cases were CFA/I, CS12, CS21, CS3, and CS6, while in asymptomatic ETEC cases were CS12, CS6 and CS21. Only few (5.7%) children had repeated infections with the same combination of ETEC toxin(s) and CFs, suggested genotype-specific immunity from each infection. For an average ETEC diarrhea episode of 5 days, reductions of 0.060 weight-for-length z-score (0.007 to 0.114; p = 0.027) and 0.061 weight-for-age z-score (0.015 to 0.108; p = 0.009) were noted in the following 30 days.

Conclusion: This study showed that ETEC is a significant pathogen in Peruvian children who experience serial infections with multiple age-specific pathotypes, resulting in transitory growth impairment.

Keywords: Peru; birth cohort; colonization factors; diarrhea; disease burden; enterotoxigenic E. coli; epidemiology; growth in children.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer DS declared a shared affiliation with the author MS to the handling editor at the time of review. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Figures

Figure 1
Figure 1
Daily incident cases of ETEC positive and ETEC negative diarrhea episodes. Daily incident cases of ETEC positive and non-ETEC diarrhea from birth to the end of the follow-up, smoothed by LOWESS (locally weighted scatterplot smoothing).
Figure 2
Figure 2
Cumulative incidence of first and subsequent ETEC diarrhea in the birth cohort. Cumulative incidence of first and subsequent ETEC diarrhea episodes in the birth cohort of 345 children. (A) Survival curves showing cumulative incidence of the first through fourth ETEC diarrhea episodes during the first two years of life. (B–D) Toxin-specific survival curves showing the cumulative incidence of the first through third episodes of ETEC diarrhea in the children 0–2 years age. (B) LT-ETEC; (C) ST-ETEC; (D) LT + ST-ETEC. Percentage is showing the cumulative incidence, and 95% confidence intervals are based on Kaplan–Meier survival analysis. (—— first infection; − - - - second infection; — • • — third infection; — - - — fourth infection).
Figure 3
Figure 3
Incidence of ETEC diarrhea episodes by age stratum. Incidence of ETEC diarrhea per 100 child-years by the type of toxins at different age groups at three months intervals. “0–24” shows the two years follow up period.
Figure 4
Figure 4
Prevalence of ETEC in diarrhea and asymptomatic routine surveillance samples. ETEC prevalence in diarrhea and non-diarrhea samples by toxin types at three months of age intervals. 0–24: the prevalence of ETEC in the total follow up period of 24 months in each child. Error bars showing 95% confidence intervals. ND: no diarrhea; D: diarrhea.
Figure 5
Figure 5
Shedding of ETEC following ETEC diarrhea and asymptomatic infections. (A) Length of shedding of ETEC following ETEC infections in the diarrhea and no diarrhea episodes. (B) Length of shedding of ETEC by the ETEC toxin types following ETEC infections in diarrhea and no diarrhea episodes. Significant differences are shown by Kruskal Wallis test and then Dunn test for pairwise comparison, (A) no diarrhea vs. diarrhea; (B) LT-ETEC vs. ST-ETEC and LT-ETEC vs. LT + ST-ETEC.
Figure 6
Figure 6
Proportion of ETEC CFs by toxin types in diarrhea and asymptomatic cases in the first and second year of life. The prevalence of CFs and associations with the ETEC toxin types by ETEC diarrhea and ETEC no diarrhea episodes among the children less than 1 year and above 1 year of age. Comparisons of CFs among diarrhea and asymptomatic cases was performed using GEE population averaged model to adjust for repeated measures. *A marginal difference was found in children less than 1 year p = 0.058 and ** a significant difference was found in children above 1 year of age p = 0.023 for CFA/I.
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References

    1. Qadri F, Svennerholm AM, Faruque AS, Sack RB. Enterotoxigenic Escherichia coli in developing countries: epidemiology, microbiology, clinical features, treatment, and prevention. Clin Microbiol Rev. (2005) 18:465–83. doi: 10.1128/CMR.18.3.465-483.2005, PMID: - DOI - PMC - PubMed
    1. Anderson JD, Bagamian KH, Muhib F, Amaya MP, Laytner LA, Wierzba T, et al. . Burden of enterotoxigenic Escherichia coli and shigella non-fatal diarrhoeal infections in 79 low-income and lower middle-income countries: a modelling analysis. Lancet Glob Health. (2019) 7:e321–30. doi: 10.1016/S2214-109X(18)30483-2, PMID: - DOI - PMC - PubMed
    1. Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, et al. . Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the global enteric multicenter study, GEMS): a prospective, case-control study. Lancet. (2013) 382:209–22. doi: 10.1016/S0140-6736(13)60844-2, PMID: - DOI - PubMed
    1. Bourgeois AL, Wierzba TF, Walker RI. Status of vaccine research and development for enterotoxigenic Escherichia coli. Vaccine. (2016) 34:2880–6. doi: 10.1016/j.vaccine.2016.02.076, PMID: - DOI - PubMed
    1. Khalil I, Troeger CE, Blacker BF, Reiner RC, Jr. Capturing the true burden of Shigella and ETEC: the way forward. Vaccine. (2019) 37:4784–6. doi: 10.1016/j.vaccine.2019.01.031, PMID: - DOI - PubMed

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