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. 2018 Oct 1;187(10):2210-2218.
doi: 10.1093/aje/kwy106.

Identification of Etiology-Specific Diarrhea Associated With Linear Growth Faltering in Bangladeshi Infants

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Identification of Etiology-Specific Diarrhea Associated With Linear Growth Faltering in Bangladeshi Infants

Amanda E Schnee et al. Am J Epidemiol. .

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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Figures

Figure 1.
Figure 1.
Pathogen detection and pathogen-specific etiology and burden of diarrhea in the Performance of Rotavirus and Oral Polio Vaccines in Developing Countries study, Bangladesh, 2011–2013. A) The proportion of diarrheal episodes in which each pathogen was detected by quantitative polymerase chain reaction. B) The attributable incidence. Bars represent 95% confidence intervals. C. jejuni, Campylobacter jejuni; EAEC, enteroaggregative Escherichia coli; E. histolytica, Entamoeba histolytica; EIEC, enteroinvasive E. coli; EPEC, enteropathogenic E. coli; GII, genogroup II; H. pylori, Helicobacter pylori; LT-ETEC, heat-labile toxin-producing enterotoxigenic E. coli; STEC, Shiga toxin-producing enterotoxigenic E. coli; ST-ETEC, heat-stable toxin-producing enterotoxigenic E. coli; V. cholerae, Vibrio cholerae.
Figure 2.
Figure 2.
Prevalence of pathogen-attributable episodes of diarrhea according to month of age in the Performance of Rotavirus and Oral Polio Vaccines in Developing Countries study, Bangladesh, 2011–2013. Estimates are shown for Campylobacter jejuni/coli (A), rotavirus (B), adenovirus 40/41 (C), Shigella/enteroinvasive Escherichia coli (D), heat-stable toxin-producing enterotoxigenic E. coli (E), norovirus genogroup II (F), sapovirus (G), astrovirus (H), Cryptosporidium (I), and enteropathogenic E. coli (J).
Figure 3.
Figure 3.
Association between etiology-specific diarrhea and linear growth attainment at 12 and 24 months in the Performance of Rotavirus and Oral Polio Vaccines in Developing Countries study, Bangladesh, 2011–2013. The effect size shown is the change in length-for-age z score per attributable episode. CI, confidence interval; EIEC, enteroinvasive Escherichia coli; ST-ETEC, heat-stable toxin-producing enterotoxigenic E. coli.
Figure 4.
Figure 4.
Association between etiology-specific diarrhea and serum C-reactive protein (CRP) in children at 6, 18, 40, and 53 weeks of age in the Performance of Rotavirus and Oral Polio Vaccines in Developing Countries study, Bangladesh, 2011–2013. Both the association between pathogen-attributable diarrhea during the entire interval as well as during the 4 weeks before each measurement is shown. CI, confidence interval; EIEC, enteroinvasive Escherichia coli; ST-ETEC, heat-stable toxin-producing enterotoxigenic E. coli.

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