- 作者：Karen L Kotloff ; James P Nataro ; William C Blackwelder ; Dilruba Nasrin ; Tamer H Farag ; S ; ra Panchalingam ; Yukun Wu ; Samba O Sow ; Dipika Sur ; Robert F Breiman ; Abu SG Faruque ; Anita KM Zaidi ; Debasish Saha ; Pedro L Alonso ; Boubou Tamboura ; Doh Sanogo ; Uma Onwuchekwa ; Byomkesh Manna ; Th ; avarayan Ramamurthy ; Suman Kanungo ; et al.
- 刊名：The Lancet
- 出版年：2013
- 出版时间：20-26 July, 2013
- 年：2013
- 卷：382
- 期：9888
- 页码：209-222
- 全文大小：480 K
Summary
Background
Diarrhoeal diseases cause illness and death among children younger than 5 years in low-income countries. We designed the Global Enteric Multicenter Study (GEMS) to identify the aetiology and population-based burden of paediatric diarrhoeal disease in sub-Saharan Africa and south Asia.Methods
The GEMS is a 3-year, prospective, age-stratified, matched case-control study of moderate-to-severe diarrhoea in children aged 0-59 months residing in censused populations at four sites in Africa and three in Asia. We recruited children with moderate-to-severe diarrhoea seeking care at health centres along with one to three randomly selected matched community control children without diarrhoea. From patients with moderate-to-severe diarrhoea and controls, we obtained clinical and epidemiological data, anthropometric measurements, and a faecal sample to identify enteropathogens at enrolment; one follow-up home visit was made about 60 days later to ascertain vital status, clinical outcome, and interval growth.
Findings
We enrolled 9439 children with moderate-to-severe diarrhoea and 13?129 control children without diarrhoea. By analysing adjusted population attributable fractions, most attributable cases of moderate-to-severe diarrhoea were due to four pathogens: rotavirus, Cryptosporidium, enterotoxigenic Escherichia coli producing heat-stable toxin (ST-ETEC; with or without co-expression of heat-labile enterotoxin), and Shigella. Other pathogens were important in selected sites (eg, Aeromonas, Vibrio cholerae O1, Campylobacter jejuni). Odds of dying during follow-up were 8¡¤5-fold higher in patients with moderate-to-severe diarrhoea than in controls (odd ratio 8¡¤5, 95 % CI 5¡¤8-12¡¤5, p<0¡¤0001); most deaths (167 [87¡¤9 % ]) occurred during the first 2 years of life. Pathogens associated with increased risk of case death were ST-ETEC (hazard ratio [HR] 1¡¤9; 0¡¤99-3¡¤5) and typical enteropathogenic E coli (HR 2¡¤6; 1¡¤6-4¡¤1) in infants aged 0-11 months, and Cryptosporidium (HR 2¡¤3; 1¡¤3-4¡¤3) in toddlers aged 12-23 months.
Interpretation
Interventions targeting five pathogens (rotavirus, Shigella, ST-ETEC, Cryptosporidium, typical enteropathogenic E coli) can substantially reduce the burden of moderate-to-severe diarrhoea. New methods and accelerated implementation of existing interventions (rotavirus vaccine and zinc) are needed to prevent disease and improve outcomes.
Funding
The Bill & Melinda Gates Foundation.