Burden of Rotavirus and Other Enteropathogens Among Children with Diarrhea in Burkina Faso

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International Journal of Infectious Diseases 15 (2011) e646–e652

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International Journal of Infectious Diseases

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Burden of rotavirus and other enteropathogens among children with diarrhea in Burkina Faso

a,b, ,1 c,1 a d b

Leon W. Nitiema * , Johan Nordgren , Djeneba Ouermi , Dayeri Dianou , Alfred S. Traore ,

c a

Lennart Svensson , Jacques Simpore

Centre de Recherche Biomole´culaire Pietro Annigoni Saint Camille CERBA/LABIOGENE, Universite´ de Ouagadougou, 01 BP 364 Ouagadougou 01, Burkina Faso

Centre de Recherche en Sciences Biologiques Alimentaires et Nutritionnelles (CRSBAN), Universite´ de Ouagadougou, 03 BP 7131 Ouagadougou 03, Burkina Faso

Division of Molecular Virology, Department of Clinical and Experimental Medicine, Linko¨ping University, Linko¨ping, Sweden

Centre National de la Recherche Scientiﬁque et Technologique, 03 BP 7047 Ouagadougou 03, Burkina Faso

A R T I C L E I N F O S U M M A R Y

Article history: Objective: There is limited information available regarding the etiology of gastrointestinal infections in

Received 28 February 2011

Burkina Faso. The aim of this study was to investigate the prevalence and epidemiology of enteric

Received in revised form 2 May 2011

pathogens causing gastroenteritis in young children, with a focus on rotavirus, and to investigate the

Accepted 11 May 2011

levels of malnutrition and other clinical factors in association with the severity of diarrhea.

Corresponding Editor: Jane Zuckerman,

Methods: A prospective study was undertaken from May 2009 to March 2010, covering the rainy and dry

London, UK.

seasons, at the Saint Camille Medical Center in Ouagadougou, Burkina Faso. A total of 309 children less

than 5 years of age with diarrhea were enrolled and examined for rotavirus, bacterial, and parasitic

Keywords: infections, as well as clinico-epidemiological aspects.

Enteropathogens

Results: At least one enteropathogen was detected in 57.9% (n = 179) of the children. Of these, 32.4% had

Rotavirus

rotavirus infections, 16.8% bacterial infections (enteropathogenic Escherichia coli 9.7%, Shigella spp 5.8%,

Malnutrition

and Salmonella spp 2.3%), and 18.8% parasitic infections (Giardia lamblia 11.3%, Trichomonas intestinalis

Severity

6.8%, Entamoeba histolytica/dispar 1.3%). During the cold dry period from December 2009 to February

2010, we observed a large increase in diarrhea cases, which was mainly attributed to rotavirus infections,

as 63.8% of these diarrhea cases were positive for rotavirus. In contrast, no rotavirus infection was

observed during the rainy season (June–September 2009), when the frequency of parasitic infections

was high. Rotavirus and parasitic infections were age-related, with rotavirus being more prevalent in

young children (<12 months) and parasites more common in older children (>12 months), while

bacteria were equally prevalent among all age groups. Rotavirus infections exhibited more severe

symptoms compared to bacteria and parasites, and were associated with fever, vomiting, and severe

dehydration. Malnutrition, especially acute malnutrition (wasting), was signiﬁcantly associated with

more severe symptoms in rotavirus-induced diarrhea. The undernourished children also exhibited a

prolonged duration of diarrheal episodes.

Conclusion: This study demonstrates rotavirus as the main etiological agent in pediatric diarrhea in

Burkina Faso, and further shows the great severity of rotavirus-induced diarrhea in undernourished

children in Burkina Faso.

1,2

1. Introduction 21% of all deaths in this age group. Gastroenteritis is often caused

by a variety of pathogenic microorganisms, such as protozoa,

3–8

Gastroenteritis is recognized as one of the most important bacteria, and viruses. Of these agents, rotavirus is known to be

public health problems in developing countries. It constitutes the the most common cause of severe acute diarrhea in young children

7,9–11

main cause of morbidity and mortality among children less than 5 in both industrialized and developing countries. Severe acute

years of age. Annually, diarrheal diseases account for up to 2.5 diarrhea due to rotavirus is estimated to cause approximately 527

million deaths among children aged less than 5 years, representing 000 deaths globally each year among children less than 5 years of

age, and it has been estimated that almost half of all deaths

(230 000) due to rotavirus occur in Africa.

In Burkina Faso, the incidence of diarrhea has been estimated to

* Corresponding author. Tel.: +226 78032030; fax: +226 50397168.

be between 6 and 8 episodes per child per year among children

E-mail address: [email protected] (L.W. Nitiema).

1 aged less than 5 years. According to the last national health

These authors contributed equally.

L.W. Nitiema et al. / International Journal of Infectious Diseases 15 (2011) e646–e652 e647

survey performed in 2008, diarrheal diseases represent the second duration and number of loose stools during the past 24 h, as well as

leading cause of death among young children (Ministry of Health, information on dehydration status, nutrition status, and whether

15,16

Burkina Faso, 2009). Very few studies from Burkina Faso have the child had been using antibiotic, antiparasitic, antipyretic or

investigated the role of rotavirus in child diarrhea, especially over analgesic medicine. All children were clinically evaluated by

an extended time-period. It is therefore essential to ﬁll in the general practitioners following a local adaptation of the World

knowledge gap regarding the epidemiology and impact of Health Organization (WHO) strategy for the management of

rotavirus, particularly in the wake of the current evaluation of diarrhea. Dehydration was classiﬁed into ‘severe dehydration’,

vaccines in other African countries. Indeed, vaccine studies ‘some dehydration’, and ‘no dehydration’, according to the WHO

performed in Ghana, Kenya, Mali, Malawi, and South Africa have guidelines.

led to promising results, but have shown less efﬁciency as

17,18

compared to trials in industrialized countries. 2.4. Anthropometric measurements to determine malnutrition status

Acute gastroenteritis is typically accompanied with dehydra-

8,19,20

tion, malnutrition, and diminished growth, and diarrhea is Infants under 2 years of age were weighed using 25-kg Salter

often more serious and more fatal in children suffering from severe hanging scales, and height was measured horizontally. Children over

malnutrition. In Burkina Faso, malnutrition in children is a public 2 years of age were weighed while standing on scales that were

health problem, and nearly 31% are estimated to be malnourished calibrated before each session, and height was measured vertically.

and 10% to be severely malnourished (Ministry of Health, Burkina The weight, height, and age of each child was recorded in a paper ﬁle.

Faso, 2009). Despite this high prevalence of malnutrition, diarrheal Weight-for-age Z-scores (‘underweight’), height-for-age Z-scores

severity, especially due to rotavirus infection has not been (‘stunting’, generally an indicator of chronic malnutrition), and

evaluated extensively. weight-for-height Z-scores (‘wasting’,generally an indicator of acute

The objective of this study was to investigate the prevalence malnutrition) were calculated using Epi Info 3.5.1 (US Centers for

and epidemiology of enteric pathogens causing gastroenteritis in Disease Control and Prevention (CDC), 2008) and the CDC/WHO

young children in Burkina Faso during the rainy and dry seasons, 1978 growth reference data. According to the WHO criteria,

with a focus on rotavirus. Another aim was to investigate the levels children were considered to be undernourished if the Z-scores were

of malnutrition and other clinical factors in association with the less than À2 standard deviations (SD) from the normal, and severely

severity of diarrhea in Burkina Faso. undernourished if the Z-scores were less than À3 SD.

2. Methods 2.5. Calculation of the severity score for diarrhea episodes

2.1. Setting A modiﬁed 14-point score system adapted from Ruuska and

23 24

Vesikari and Nakagomi et al. was applied in order to evaluate the

The study was conducted at the Saint Camille Medical Center in severity of diarrhea. This score system was adapted to the clinical

Ouagadougou, the capital of Burkina Faso. The city is located in the information obtained in this study and takes into account all the

center of the country and has an estimated population of almost 2 clinical information available. The score was calculated as follows:

million inhabitants (Demographic Research Center, Burkina Faso, duration of diarrhea at the time of sampling: 1–3 days = 1 point, 4–5

2002). The climate is Sahelian, with a rainy season during June to days = 2 points, 6 days = 3 points; number of stools in the last 24 h:

September, and a long dry season from October to May, in which a 1–3 stools = 1 point, 4–5 stools = 2 points, 6 stools = 3 points;

colder period is observed during December to February. Sanitary vomiting: no vomiting = 0 point, vomiting = 2 points;

conditions are insufﬁcient in large sections of the city, especially in fever: < 37.1 8C = 0 point, 37.1–38.4 8C = 1 point, 38.5–38.9 8C = 2

the peripheral areas. Patients coming to the Saint Camille Medical points, 39.0 8C = 3 points; dehydration: no dehydration = 0 point,

Center (CERBA/LABIOGENE) are generally poor, and children less moderate dehydration = 2 points, severe dehydration = 3 points.

than 5 years of age seen at the pediatric service often suffer from

malnutrition. Malnourished children attend the nutritional recu- 2.6. Sampling and preliminary analysis of enteric pathogens

peration center for mothers and children where anthropometric

measurements are taken for nutritional follow-up. Fecal specimens were collected in sterile containers and stored at

4 8C at the microbiology laboratory of the Saint Camille Medical

2.2. Study design Center (CERBA/LABIOGENE). One 10% (wt/vol.) suspension of the

stool was prepared with phosphate-buffered saline (pH 7.2), and a

During the study period from the end of May 2009 to the middle second suspension was prepared using ELISA buffer (ProSpect

of March 2010, a total of 309 children aged less than 5 years with Rotavirus kit R240396). All aliquots were frozen at À20 8C until used

diarrhea were enrolled in a prospective manner. After informed for enteric virus detection. Escherichia coli, Shigella spp, Salmonella

consent was given, epidemiological information for each case was spp, and Candida albicans were investigated by conventional culture

obtained from the parents or the child’s guardians and registered in procedures. E. coli isolates were further examined with E. coli

a paper ﬁle. After examination, each child was referred to either the Trivalent I, II, III and IV antiserum tests to identify enteropathogenic

pediatric service or the nutritional recuperation center where a E. coli (EPEC). Bacterial sensitivity testing was carried out using

decision regarding follow-up treatment (oral rehydration solution antibiotic disks on Mueller–Hinton broth. Parasites (Entamoeba

(ORS), drugs) or hospitalization was taken. The study was approved histolytica/dispar, Giardia lamblia, Trichomonas intestinalis, Hymeno-

by the local ethics committee for bioethics research at Saint lepis nana and Ancylostoma) and yeasts were investigated using

Camille Medical Center (CERBA/LABIOGENE). conventional microscopy and staining methods. Furthermore, the

presence of mucus or blood in stool, as well as the characteristics of

2.3. Clinical assessment the stool, was determined.

Clinical information was obtained by reviewing the clinical 2.7. Rotavirus antigen detection

records of each case. The information was registered in a paper ﬁle

and included age, sex, place of residence, ethnicity, and symptoms Rotavirus antigen was detected in the stool supernatant by

such as fever ( 38 8C), nausea, vomiting, loss of appetite, and ELISA using a commercial kit (ProSpect Rotavirus kit, R240396), in

e648 L.W. Nitiema et al. / International Journal of Infectious Diseases 15 (2011) e646–e652

Table 1

accordance with the manufacturer’s instructions. The results were

Enteropathogens identiﬁed in children suffering from diarrhea (N = 309)

visually read and conﬁrmed by absorbance measurements.

Enteropathogen No. of positives (%)

2.8. Statistical analysis

Rotavirus 100 (32.4)

Bacteria 52 (16.8)

Statistical analysis was performed using SPSS software version Enteropathogenic Escherichia coli 30 (9.7)

Shigella spp 10 (3.2)

17.0 (SPSS, Chicago, IL, USA). Malnutrition was evaluated using

Shigella ﬂexneri 6 (1.9)

Nutrition StatCalc from Epi Info 3.5.1 (US Centers for Disease

Shigella boydii 1 (0.3)

Control and Prevention (CDC), 2008) and the CDC/WHO 1978

Shigella sonnei 1 (0.3)

growth reference data. Children positive for rotavirus, bacteria, and Salmonella spp 7 (2.3)

Parasites 58 (18.8)

parasites were compared in terms of gender, age group,

Giardia lamblia 35 (11.3)

breastfeeding status, and nutritional status using the Chi-square

Trichomonas intestinalis 21 (6.8)

test or Fisher’s exact test. Differences in severity scores were

Entamoeba histolytica/dispar 4 (1.3)

analyzed by independent t-test or one-way analysis of variance Hymenolepis nana 0 (0)

(one-way ANOVA) using Tukey’s post-hoc test. A p-value of < 0.05 Ancylostoma 0 (0)

was considered signiﬁcant. a

Including mixed infections.

3. Results

3.1. General epidemiological characteristics of children enrolled in the January (Figure 1). We found that this notable increase in diarrhea

study cases was associated with rotavirus infections. During December

2009 to February 2010, we observed a remarkable increase in

The children enrolled in the study (N = 309) were mainly from rotavirus-positive cases. During these 3 months, rotavirus was

the urban area of Ouagadougou (94%), and the rest came from found in 63.8% (97/152) of the cases, with a peak in January, when

villages near to the capital. Most of the urban patients (80%) lived most cases of rotavirus-associated gastrointestinal infections were

in peripheral districts of Ouagadougou where sanitary conditions found. Bacterial infections also showed a small increase during this

are often insufﬁcient. Among enrolled patients, the percentage of period, whereas the prevalence of parasite infections remained low

boys was slightly higher in comparison to girls (53% vs. 47%). The (Figure 1).

mean age of the enrolled children was 14 months (range 1.6 to 48

months). Persistent diarrhea (duration >14 days) was observed in 3.3. High prevalence of parasites but no rotavirus infections found

17 (5.5%) children. Additionally, a large number of children (57%) during the rainy season

were considered underweight (Z < À2 SD; weight-for-age score).

Many children had taken antibiotic or antiparasitic drugs within The prevalence of parasites was relatively high during the rainy

the 24 h prior to arriving at the health center (47% and 32%, season, from June to August, with a prevalence rate of 28% (28/

respectively). Also, a high number (29%) had taken antipyretic and 100). In contrast, no rotavirus and fewer bacterial infections were

analgesic drugs, such as paracetamol or ibuprofen, within the 24 h observed during this season (Figure 1). Among the parasitic

prior to coming to the health center. pathogens isolated, G. lamblia was the most predominant

pathogen, detected in 11.3% (n = 35) of cases, followed by T.

3.2. An increase in diarrhea cases in the cold dry season was intestinalis (6.8%, n = 21) and E. histolytica/dispar (1.3%, n = 4)

associated with rotavirus (Table 1).

At least one enteric pathogen was found in 179 (57.9%) cases. 3.4. Enteropathogenic E. coli was the most prevalent bacterium

Rotavirus, parasites, and bacteria were observed in 100 (32.4%), 58 isolated

(18.8%), and 52 (16.8%) cases, respectively (Table 1). During the

study period, we observed a substantial increase in diarrhea cases No clear seasonal variation of bacterial infections was noted

during December to mid February (cold dry season), with a peak in during the time-period investigated (Figure 1), although a small

40 100

35 90 80 30 70 25 60 20 50 % 15 40 30 10 20 5 10

0 0

Dry season Rainy season Dry season Cold dry season Dry season

May-09 March-10

Rotavirus (n) Bacteria (n) Parasites (n)

Rotavirus (%) Bacteria (%) Parasites (%)

Figure 1. Seasonality of rotavirus, bacteria, and parasites detected in children with diarrhea in Burkina Faso. Rainy season: June 2009–September 2009; cold dry season:

December 2009–February 2010. Each data point represents 3 weeks of sampling..

L.W. Nitiema et al. / International Journal of Infectious Diseases 15 (2011) e646–e652 e649

Table 2

Characteristics of the pediatric population in relation to infection with the different enteropathogens

a a a

Parameter No. Rotavirus, n (%) p-Value Bacteria, n (%) p-Value Parasite, n (%) p-Value

Gender

Male 164 51 (31) 0.61 29 (18) 0.67 30 (18) 0.82

Female 145 49 (34) 23 (16) 28 (19)

Age range (months)

0–<6 20 9 (45) 0.089 4 (20) 0.95 0 (0) <0.01

6–<12 115 44 (38) 17 (15) 11 (10)

12–24 139 40 (29) 25 (18) 31 (22)

>24 35 7 (20) 6 (17) 16 (46) b,c

Breastfeeding status

Exclusively breastfed 22 6 (27) 0.15 3 (14) 1.00 1 (5) 0.35

Non-exclusively breastfed 107 41 (38) 19 (18) 9 (8)

Not breastfed 9 6 (67) 1 (11) 2 (22)

Uncorrected Chi-square test.

Evaluated only for children of 12 months of age due to the fact that mothers in Burkina Faso rarely breastfeed after this age.

Fisher’s exact test (breastfed (exclusively and non-exclusively) vs. not breastfed).

increase was observed during the cold dry season and a small tively). However, a high prevalence of rotavirus was found in the

decrease noted during the rainy season. Overall, 52 (16.8%) group that did not breastfeed (6/9, 67%), as compared to those that

samples were found positive for bacterial infection. Among only breastfed (6/22, 27%, p = 0.15) (Table 2).

bacterial pathogens, EPEC was most frequently detected (9.7%;

n = 30), followed by Shigella spp (3.2%; n = 10), Salmonella spp (2.3%; 3.6. Severity and clinical features of rotavirus infections

n = 7), Shigella ﬂexneri (1.9%; n = 6), Shigella boydii (0.3%; n = 1), and

Shigella sonnei (0.3%; n = 1) (Table 1). To accurately describe a clinical proﬁle of gastroenteritis, it was

necessary to separate all co-infections into a mixed group, thus

3.5. Rotavirus and parasitic infections were associated with age describing symptoms only for rotavirus, bacteria, and parasites

separately. In 24 out of 100 rotavirus-positive cases, at least one

Infection with the different pathogens was not associated with more pathogen was found, mostly bacteria (n = 18). The children

gender (Table 2). Children less than 2 years of age were infected infected only with rotavirus presented the following symptoms:

more frequently with rotavirus than children aged between 2 and 5 fever 38.0 8C (42%), vomiting (82%), watery stool (83%), 6 stools

years (p = 0.06). The highest prevalence of rotavirus was found in in the past 24 h (28%), and severe dehydration (24%). Comparing

children aged less than 6 months (45%). In contrast, for parasitic rotavirus symptoms to those of parasites and bacteria, we

infections the situation was the opposite, with children >2 years observed a signiﬁcant difference for all symptoms, except the

having a higher parasite infection rate (p < 0.01), with 46% of older number of loose stools (Table 3). Mixed infections were observed

children having parasite infections (Table 2). Bacterial infections in 10.0% (n = 31) of the diarrhea cases (Table 3) and were slightly

were not signiﬁcantly different between age groups. Additionally, more frequent in children aged >24 months (14.3%). The majority

breastfeeding did not signiﬁcantly protect against rotavirus, of mixed infections included rotavirus (24/31), with the following

bacterial, or parasitic infections (p = 0.15, 0.99, and 0.35, respec- combinations: rotavirus and G. lamblia (n = 3), rotavirus and T.

Table 3

Clinical features in children with diarrhea

a b

Clinical feature Rotavirus (n = 76), n (%) Bacteria (n = 27), n (%) Parasite (n = 45), n (%) Mixed infection (n = 31), n (%) p-Value

Fever (38 8C) 32 (42) 7 (26) 7 (16) 19 (61) p < 0.01

Duration of diarrhea (days)

1–3 40 (53) 7 (26) 20 (44) 17 (55)

4–5 23 (30) 7 (26) 6 (13) 6 (19)

6 13 (17) 13 (48) 19 (42) 8 (26) p < 0.001

Vomiting 62 (82) 7 (26) 10 (22) 20 (65) p < 0.001

Loss of appetite 62 (82) 22 (81) 23 (51) 23 (74) p < 0.01

Mucus 36 (47) 16 (59) 11 (24) 15 (48) p = 0.23

Number of loose stools in the past 24 h

1–3 28 (37) 4 (15) 18 (40) 14 (45)

4–5 27 (36) 16 (59) 14 (31) 8 (26)

6 21 (28) 7 (26) 13 (29) 9 (29) p = 0.98

Stools

Watery 63 (83) 17 (63) 14 (31) 26 (84) p < 0.001

Loose 13 (17) 10 (37) 31 (69) 5 (16)

Dehydration status

Severe dehydration 18 (24) 2 (8) 4 (9) 5 (16) p = 0.014

Some dehydration 38 (50) 16 (64) 22 (49) 19 (61)

No dehydration 20 (26) 7 (28) 19 (42) 7 (23)

d e

Severity score 7.99 Æ 2.14 7.36 Æ 1.89 6.13 Æ 2.25 7.90 Æ 2.14 p < 0.001

Including rotavirus and bacteria (n = 18), rotavirus and parasites (n = 6), bacteria and parasites (n = 7); not including mixed bacterial infections (n = 2).

Uncorrected Chi-square test, rotavirus vs. bacteria and parasites.

Dehydration status lacking for two bacteria-positive children.

14-point scale, as described in the Methods section.

One-way analysis of variance; statistical differences between groups were determined using Tukey’s post-hoc test; p < 0.05 was observed between rotavirus and parasite

infections, as well as for mixed infections compared to parasite infections.

e650 L.W. Nitiema et al. / International Journal of Infectious Diseases 15 (2011) e646–e652

intestinalis (n = 3), rotavirus and EPEC (n = 15), rotavirus and a mean Z-score of À1.99, whereas children with diarrhea of less

Shigella spp (n = 2), and rotavirus and Salmonella spp (n = 1). We than 6 days had a mean Z-score of À1.43 (p = 0.036; independent t-

also observed that mixed infections had a similar clinical proﬁle test). A similar difference was also noted for parasite infections

and severity score as compared to rotavirus infections. One notable (p = 0.051; independent t-test), but not for bacterial infections

difference was the higher prevalence of fever in the mixed (p = 0.87).

infection group (61% as compared to 42% for rotavirus, p = 0.07). Regarding chronic malnutrition, no statistically signiﬁcant

While comparing clinical severity scores between the different increase in the duration of diarrhea was observed for parasitic

enteropathogens, we observed the highest severity scores in the or bacterial infections. However, for severely stunted children (Z

rotavirus and mixed infections groups. However, these differences À3 SD), a borderline statistical signiﬁcance was observed with

were only statistically signiﬁcant (p < 0.05) when comparing rotavirus infection (mean 5.0 vs. 3.5 days duration before arriving

rotavirus and mixed infections to parasite infections (Table 3). at the health center; p = 0.06).

3.7. High resistance of bacteria to the commonly used antimicrobial 4. Discussion

co-trimoxazole

In this study we investigated the impact of rotavirus and other

Antimicrobial susceptibility was tested for all bacteria isolated enteropathogens, as well as the implications of malnutrition, in

except EPEC. The most commonly tested strain was Shigella spp children suffering from diarrhea in Burkina Faso. We observed that

(n = 18), for which 72% (n = 13) of the strains exhibited resistance children less than 12 months of age were susceptible to diarrhea,

to co-trimoxazole, 50% (n = 9) to ampicillin, and 33% (n = 6) to comprising 44% of all the diarrhea cases. Similar results have been

14,15,25

chloramphenicol and amoxicillin with clavulanate. No resistance obtained in other studies from Burkina Faso. This is likely

was observed towards lincomycin. Of the seven Salmonella due to the naive immune system in children of younger ages, and

26–28

specimens tested, 71% (n = 5) were resistant to amoxicillin with also due to the waning of maternal antibodies following birth.

clavulanate, 57% (n = 4) to co-trimoxazole and chloramphenicol, Also, at such an age children generally start to take supplement

and 43% (n = 3) to ampicillin. The high resistance to co-trimoxazole foods in addition to breastfeeding, something which in low-income

26,29

is of particular concern, since among the children already having countries frequently leads to malnutrition and diarrhea.

taken antibiotics when arriving at the health center (n = 145), Of all the etiologic agents detected during the study, group A

almost 65% (n = 94) had used the antibiotic co-trimoxazole. rotavirus was found in a total of 32.4% of the cases, conﬁrming its

role as the main etiological agent in pediatric diarrhea. Other

3.8. Malnutrition was associated with severity and duration of studies from West Africa have reported prevalence rates ranging

14,16,30,31

diarrhea from 18% to 41%. During the cold dry season (December

2009–February 2010), we observed a rotavirus prevalence of

In our study, we used three malnutrition indicators: under- 63.8%, thereby demonstrating a marked seasonality of rotavirus

weight, stunting (chronic malnutrition), and wasting (acute infection in Burkina Faso. Indeed, during some weeks in the cold

malnutrition). We observed that 57% of the children enrolled in dry period, up to 90% of all diarrhea cases were related to rotavirus

the study were underweight (Z < À2 SD; weight-for-age score), infections (Figure 1). Also during this period, the rate of bacterial

31% suffered from stunting (Z < À2 SD; length-for-age score), and infections increased, resulting in a large number of mixed rotavirus

46% suffered from wasting (Z < À2 SD; weight-for-length score). and bacterial infections. Similar observations have also been

Malnutrition was more prevalent in older children (>12 months) reported from Burkina Faso and other bordering countries, such as

16,31,32

(data not shown). The clinical severity score for diarrhea increased Mali and Ghana. Parasites and bacteria were present

with malnutrition for all malnutrition indicators. The increase was alternately during the study period, with parasites having a higher

particularly notable for the wasting indicator (Table 4), especially relative frequency during the rainy season, a period during which

for rotavirus and mixed infections. We also observed that children we did not detect any rotavirus infection.

suffering from wasting exhibited the most severe forms of While breastfeeding has been associated with decreased rates

33,34

diarrhea. Furthermore, we observed that acute malnutrition was of diarrhea in infants in developed and developing countries,

associated with the duration of diarrhea for rotavirus infections. several studies have reported no difference in rotavirus incidence,

Children with rotavirus-associated diarrhea for 6 or more days had although some differences in symptoms have been observed. In

Table 4

Malnutrition indicators in relation to the presence of the different enteropathogens and severity of diarrhea

Z-score Total Rotavirus Severity Bacteria Severity Parasite Severity Mixed Severity

(n = 76), score (n = 25), score (n = 45), score infections score

n (%) n (%) n (%) (n = 31), n (%)

Underweight status

Z > À2 SD 131 46 (35) 7.61 Æ 2.24 8 (6) 6.25 Æ 2.25 13 (10) 4.85 Æ 2.44 16 (12) 7.13 Æ 1.86

À3 SD < Z < À2 SD 82 21 (26) 8.48 Æ 1.81 6 (7) 8.00 Æ 1.55 22 (27) 6.82 Æ 2.06 8 (10) 9.25 Æ 2.19

Z < À3 SD 94 9 (10) 8.78 Æ 2.11 11 (12) 7.82 Æ 1.54 10 (11) 6.30 Æ 1.83 7 (7) 8.14 Æ 2.12

Stunting status

Z > À2 SD 207 61 (29) 8.02 Æ 2.17 14 (7) 7.00 Æ 2.11 27 (13) 5.89 Æ 2.39 24 (12) 7.67 Æ 2.24

À3 SD < Z < À2 SD 58 10 (17) 7.60 Æ 1.78 5 (9) 8.20 Æ 1.92 11 (19) 7.00 Æ 2.05 3 (5) 8.33 Æ 2.08

Z < À3 SD 39 5 (13) 8.40 Æ 2.70 6 (15) 7.50 Æ 1.23 7 (18) 5.71 Æ 1.89 4 (10) 9.00 Æ 1.41

Wasting status

c c

Z > À2 SD 161 48 (30) 7.50 Æ 2.23 11 (7) 6.55 Æ 2.07 22 (14) 6.00 Æ 2.39 18 (11) 6.89 Æ 1.88

À3 SD < Z < À2 SD 90 23 (26) 8.70 Æ 1.80 10 (11) 7.70 Æ 1.42 17 (19) 6.06 Æ 2.41 9 (10) 8.89 Æ 1.76

Z < À3 SD 53 5 (9) 9.40 Æ 1.14 4 (8) 8.75 Æ 1.71 6 (11) 6.83 Æ 1.17 4 (8) 10.25 Æ 0.96

Underweight status (n = 307): weight-for-age Z-scores; stunting status (n = 304): height-for-age Z-scores; wasting status (n = 304): weight-for-height Z-scores.

Including rotavirus and bacteria (n = 18), rotavirus and parasites (n = 6), and bacteria and parasites (n = 7).

p < 0.05 using one-way analysis of variance (one-way ANOVA).

L.W. Nitiema et al. / International Journal of Infectious Diseases 15 (2011) e646–e652 e651

our study, we did not observe any signiﬁcant protection against bacteria-induced diarrhea in the study area, strongly indicates that

rotavirus in breastfed children (p = 0.15, Table 2). However, the the frequent and often uncritical use of antibiotics should be better

prevalence of rotavirus infections in children who were not regulated, and education measures with regard to the use of

breastfed was high (67%, 6/9) in comparison to those who were antibiotics should be implemented in Burkina Faso. Similar

breastfed (36%, 47/129). Due to the small number of non-breastfed problems have also been reported in the neighboring country of

children we could not adequately examine the relationship Ghana.

between exclusive breastfeeding and rotavirus diarrhea. Also, Malnutrition increased the severity of diarrhea as measured

for the same reasons, it was difﬁcult to assess differences in with the severity score, especially when the children were acutely

severity. It is possible that a signiﬁcant difference would have been malnourished (wasting). The association between wasting and the

observed if the number was higher. Also, this could be due to the severity of diarrhea is of special interest. This suggests that the

fact that the maternal antibodies were not speciﬁc to the rotavirus wasting indicator should be used when assessing the severity of

strains circulating during this period. diarrhea in developing countries where malnutrition is a concern.

Parasites constituted the second largest etiologic agents of The highest severity score was found in children suffering from

diarrhea detected in this study (18.8%). The incidence of intestinal severe wasting and infected with rotavirus or with multiple

parasites was especially high in children aged more than 24 pathogens, of which the majority were rotavirus-associated. For

months, in whom we observed a 46% prevalence. Similar parasitic infections, however, the wasting indicator was not

observations have been reported in earlier studies from Burkina signiﬁcantly associated with the severity of diarrhea; instead

Faso. The predominance of parasites in this age group is likely the underweight indicator was signiﬁcantly associated with a

due to the transmission of these pathogens by food and drink. The higher severity (Table 4).

prevalence of parasites was relatively high during the rainy season, Furthermore, we observed that the duration of rotavirus-

from June to August. G. lamblia, the most prevalent parasite (11.3%) induced diarrhea was associated with acute malnutrition. Children

observed in our study, is known to be ubiquitously present in water suffering from rotavirus-associated diarrhea for 6 or more days had

and food in Burkina Faso. a mean Z-score of À1.99, whereas children with diarrhea of less

Bacterial pathogens were found in 16.8% of the cases. All age than 6 days duration had a mean Z-score of À1.43 (p = 0.036;

groups were affected by bacterial infections at similar rates. We independent t-test), a difference also noted for parasitic infections.

observed more bacterial infections during the cold dry season as This is of concern since many diarrhea-related deaths are

compared to the rainy season. This is similar to a study from associated with prolonged diarrheal episodes and malnutri-

21,41

Tanzania, which found a higher prevalence of diarrheagenic E. coli tion; thus this further demonstrates the high burden of

and Shigella during the dry season. The isolated bacteria are rotavirus infections in undernourished children in Burkina Faso. Of

indicators of fecal contamination, indicating low hygiene in the all cases of children suffering from persistent diarrhea (duration

intake of foods. EPEC was found in 58% (30/52) of all diarrhea >14 days; n = 17) where an enteropathogen was detected, 89% (8/

cases from which bacteria were isolated. Therefore, EPEC is the 9) were considered underweight (Z < À2 SD; weight-for-age

bacterium most implicated in pediatric diarrhea in our study. score), indicating that malnutrition prolongs the diarrheal disease,

41,42

These results are in concordance with the results of previous something which has been reported previously. Of all

studies in developing countries, but differ from those found by rotavirus-positive children, 40% were considered underweight

38 14

Bonﬁglio et al. (35%) and Simpore et al. (37.5%) in studies from (Z < À2 SD; weight-for-age score) underlining the problems

Burkina Faso in which a higher prevalence of EPEC was found. A concerning rotavirus disease burden in undernourished children

large number of the children in our study were on antibiotic in Burkina Faso.

treatment (47%) before coming to the health center, which may In 42% of our diarrhea cases, no pathogens could be found. This

have reduced the number of bacterial pathogens detected. An could be due to the fact that not all enteropathogens were

increased number of stool samples per patient and the use of PCR investigated, e.g., Campylobacter, enterotoxigenic E. coli, adenovi-

7,8,15,29

methods would give a better indication of the prevalence of rus, norovirus, and sapovirus. Moreover, several children

bacteria-induced diarrhea in this region. arriving at the health center had already taken antiparasitic and

Rotavirus infections resulted in more severe symptoms in antibiotic drugs, which may have decreased the odds of detecting

comparison to bacterial and parasitic infections, with 42% of parasitic and bacterial pathogens.

children with rotavirus infections experiencing fever, 82% In conclusion, in this study we investigated the burden of

experiencing vomiting, and 24% being severely dehydrated. rotavirus and other enteropathogens and their association with

Rotavirus-induced diarrhea demonstrated a more acute clinical malnutrition among children suffering from diarrhea in Burkina

proﬁle with a lower duration than diarrhea as a result of bacterial Faso. The diarrheal disease was mainly associated with rotavirus,

or parasitic infections. Mixed infections were observed in 10.0% of G. lamblia, and EPEC, and also exhibited a strong seasonality.

the cases, most of them including rotaviruses. They showed a Rotavirus infections were associated with the large increase in

similar clinical proﬁle to that of single rotavirus infections, with diarrhea cases during the cold dry season, and were furthermore

the exception of fever, which was more prevalent in the mixed associated with severe dehydration, vomiting, and fever. An

infections group (61% vs. 42%, Table 3). increased prevalence of rotavirus infection was also found in

Gastroenteritis due to EPEC infections is cured locally at the children who did not breastfeed. The wasting parameter, indicat-

Saint Camille Medical Center by the use of minerals and ing acute malnutrition, was associated with a signiﬁcant increase

rehydration therapy. For other bacteria like Salmonella spp and in the severity scores in rotavirus infections, suggesting that this

Shigella spp, antibiotics are commonly used in Burkina Faso. The parameter could be used to assess diarrhea severity.

incorrect use of antibiotics has resulted in a very high prevalence of

resistance. In this study, Salmonella spp and Shigella spp were

found highly resistant to co-trimoxazole, ampicillin, chloram- Acknowledgements

phenicol, and amoxicillin with clavulanic acid, which are

commonly used in Burkina Faso. Indeed, among the children We would like to acknowledge the staff of the pediatric unit, the

who had already taken antibiotics before arriving at the health nutritional recuperation center for mothers and children, and the

center (n = 145), 65% had used co-trimoxazole. This high preva- laboratory unit of the Saint Camille Medical Center (CERBA/

lence of resistance in combination with the more limited role of LABIOGENE) of Ouagadougou for their co-operation.

e652 L.W. Nitiema et al. / International Journal of Infectious Diseases 15 (2011) e646–e652

18. Madhi SA, Cunliffe NA, Steele D, Witte D, Kirsten M, Louw C, et al. Effect of

Funding source: The study was supported by grants from the

human rotavirus vaccine on severe diarrhea in African infants. N Engl J Med

Swedish Research Council (grant 10392). 2010;362:289–98.

Ethical approval: The study was approved by the local ethics 19. Checkley W, Epstein LD, Gilman RH, Cabrera L, Black RE. Effects of acute

diarrhea on linear growth in Peruvian children. Am J Epidemiol

committee for bioethics research at Saint Camille Medical Center 2003;157:166–75.

(CERBA/LABIOGENE).

20. Black RE. Would control of childhood infectious diseases reduce malnutrition?

Conﬂict of interest: The authors declare that they have no Acta Paediatr Scand Suppl 1991;374:133–40.

21. Yoon PW, Black RE, Moulton LH, Becker S. The effect of malnutrition on the risk

competing interests.

of diarrheal and respiratory mortality in children <2 y of age in Cebu,

Philippines. Am J Clin Nutr 1997;65:1070–7.

22. Waterlow JC, Buzina R, Keller W, Lane JM, Nichaman MZ, Tanner JM. The

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