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WHAT CAUSES DIARRHEA IN THE UNITED STATES? Risk Factors for and Causes of Diarrhea in Selected Jurisdictions in the United StatesBackground: In the United States, an estimated 9.4 million foodborne related illnesses from known pathogens and 38.4 million foodborne related illnesses from unknown causes occur annually. It is critically important to improve our ability to identify enteric pathogens and to characterize risk factors associated with potentially distinct diarrheal illnesses. Objectives: Risk factors for hospital admission among patients with diarrhea are not well characterized. In this study, we analyzed risk factors for hospitalization among outpatients with complaints of diarrhea, focusing on patients with multiple enteric pathogens. Additionally, we investigated the most commonly recognized infectious cause of diarrhea among hospitalized individuals, Clostridium difficile, in order to better understand its increasing frequency in community-onset diarrhea. Methods: Through the use of core epidemiologic methodology in combination with state-of-the-art laboratory techniques, known and putative pathogens were identified in patients with diarrhea presenting to selected emergency departments and ambulatory care clinics in Baltimore, Maryland, and New Haven, Connecticut from 2002-2007. Results: Of 1197 outpatients with diarrhea, 405 (35.0%) had definitive enteric pathogens, 527 (45.8%) had definitive or possible pathogens, 62 (5.4%) had multiple definitive pathogens, and 142 (12.3%) had multiple definitive or possible pathogens. At presentation, 233 patients (19.5%) were admitted to the hospital and 919 (76.8%) were not. When forced into a multivariable logistic regression model, multiple enteric pathogens (odds ratio (OR)=0.86, 95% confidence interval (CI)=0.61-1.21) lacked significance; however, age >65 (OR=7.2, 95% CI=4.16-12.46), history of prior gastrointestinal (OR=3.65, 95% CI=2.12-6.29) or immunocompromising co-morbid conditions (OR=2.67, 95% CI=1.69-4.21), hospitalization in the previous month (OR=3.24, 95% CI=2.07-5.07), and presentation at an emergency department (OR=2.53, 95% CI=1.72-3.73) were significantly associated with hospitalization. Of 1,091 outpatients tested for C. difficile toxin, 43 (3.9%) had positive results. Seven had no recognized risk factors, and three of these had neither risk factors nor co-infection with another enteric pathogen. Conclusions: A significant portion of outpatients with diarrhea were hospitalized. Identification of enteric pathogens or multiple pathogens was not associated with increased likelihood for hospitalization after adjustment for age and past medical conditions. Additionally, most outpatients with C. difficile infection had either recognized risk factors or co-infection.
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Maternal diarrhea and antibiotic use are associated with increased risk of diarrhea among HIV-exposed, uninfected infants in KenyaHIV-exposed, uninfected (HEU) children are a growing population at particularly high risk of infection-related death in whom preventing diarrhea may significantly reduce under-5 morbidity and mortality in sub-Saharan Africa. A historic cohort (1999-2002) of Kenyan HEU infants followed from birth to 12 months was used. Maternal and infant morbidity were ascertained at monthly clinic visits and unscheduled sick visits. The Andersen-Gill Cox model was used to assess maternal, environmental, and infant correlates of diarrhea, moderate-to-severe diarrhea (MSD; diarrhea with dehydration, dysentery, or related hospital admission), and prolonged/persistent diarrhea (> 7 days) in infants. HIV-exposed, uninfected infants (n = 373) experienced a mean 2.09 (95% CI: 1.93, 2.25) episodes of diarrhea, 0.47 (95% CI: 0.40, 0.55) episodes of MSD, and 0.34 (95% CI: 0.29, 0.42) episodes of prolonged/persistent diarrhea in their first year. Postpartum maternal diarrhea was associated with increased risk of infant diarrhea (Hazard ratio [HR]: 2.09; 95% CI: 1.43, 3.06) and MSD (HR: 2.89; 95% CI: 1.10, 7.59). Maternal antibiotic use was a risk factor for prolonged/persistent diarrhea (HR: 1.63; 95% CI: 1.04, 2.55). Infants living in households with a pit latrine were 1.44 (95% CI: 1.19, 1.74) and 1.49 (95% CI: 1.04, 2.14) times more likely to experience diarrhea and MSD, respectively, relative to those with a flush toilet. Current exclusive breastfeeding was protective against MSD (HR: 0.30; 95% CI: 0.15, 0.58) relative to infants receiving no breast milk. Reductions in maternal diarrhea may result in substantial reductions in diarrhea morbidity among HEU children, in addition to standard diarrhea prevention interventions.
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Household costs of diarrhea by etiology in 7 countries, the Global Enterics Mulitcenter Study (GEMS)Background. Although there are many overlapping features, pediatric diarrheal diseases can vary in severity, duration, clinical manifestations, and sequelae according to the causal pathogen, which in turn can impact the economic burden on patients and their families. We aimed to evaluate the household costs of diarrheal disease by pathogen in 7 countries. Methods. We analyzed data from the Global Enteric Multicenter Study (GEMS), a prospective, age-stratified, matched case- control study of moderate to severe diarrheal disease among children aged 0-59 months in 7 low-income countries; 4 in Africa (Kenya, Mali, Mozambique, The Gambia) and 3 in Asia (Bangladesh, India, Pakistan). Demographic, epidemiological, economic, and clinical data were collected, and a stool sample was obtained for microbiological analysis at enrollment. We used a multivariate generalized linear model to assess the effect of rotavirus, Cryptosporidium, heat-stable toxin (ST)-producing enterotoxigenic Escherichia coli (ETEC [ST only or LT plus ST]), Shigella, Campylobacter jejuni, norovirus GII, Vibrio cholerae O1, age, gender, in/ outpatient, and country on total costs to the patient/family. Results. Household out-of-pocket costs were higher in Mali than any other country. Within countries, household cost differences between pathogens were minimal and not statistically significantly different. Conclusions. We found no significant differences in household costs by pathogen. Despite data limitations, understanding pathogen-specific household costs (or lack thereof) is useful, as decision-makers could consider broader illness cost information and its relevance to a particular pathogen's economic burden and contribution to poverty when deciding which pathogens to target for interventions. © The Author(s) 2019.
