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Surveillance Study of Acute Gastroenteritis Etiologies in Hospitalized Children in South Lebanon (SAGE Study)

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Surveillance Study of Acute Gastroenteritis Etiologies in Hospitalized Children in South Lebanon (SAGE Study) pISSN: 2234-8646 eISSN: 2234-8840 https://doi.org/10.5223/pghn.2018.21.3.176 Pediatr Gastroenterol Hepatol Nutr 2018 July 21(3):176-183 Original Article PGHN Surveillance Study of Acute Gastroenteritis Etiologies in Hospitalized Children in South Lebanon (SAGE study) Ghassan Ghssein, Ali Salami, Lamis Salloum, Pia Chedid*, Wissam H Joumaa, and Hadi Fakih† Rammal Hassan Rammal Research Laboratory, Physio-toxicity (PhyTox) Research Group, Lebanese University, Faculty of Sciences (V), Nabatieh, *Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Balamand, †Department of Pediatrics, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon Purpose: Acute gastroenteritis (AGE) is a major cause of morbidity and remains a major cause of hospitalization. Following the Syrian refugee crisis and insufficient clean water in the region, this study reviews the etiological and epidemiological data in Lebanon. Methods: We prospectively analyzed demographic, clinical and routine laboratory data of 198 children from the age of 1 month to 10 years old who were admitted with the diagnosis of AGE to a private tertiary care hospital located in the district of Nabatieh in south Lebanon. Results: Males had a higher incidence of AGE (57.1%). Pathogens were detected in 57.6% (n=114) of admitted pa- tients, among them single pathogens were found in 51.0% (n=101) of cases that consisted of: Entamoeba histolytica 26.3% (n=52), rotavirus 18.7% (n=37), adenovirus 6.1% (n=12) and mixed co-pathogens found in 6.6% (n=13). Breast-fed children were significantly less prone to rotavirus (p=0.041). Moreover, children who had received the rota- virus vaccine were significantly less prone to rotavirus (p=0.032). Conclusion: Our findings highlight the high prevalence of E. histolytica infection as the major cause of pediatric gastro- enteritis in hospitalized children, during the summer period likely reflecting the insanitary water supplies and lack of hygiene. Moreover the 42.4% of unidentified causative pathogens should prompt us to widen our diagnostic laboratory arsenal by adopting new diagnostic technologies. Key Words: Gastroenteritis, Rotavirus, Amebiasis, Diarrhea, Lebanon INTRODUCTION dren in developing countries [1]. It is characterized by diarrhea, vomiting and abdominal pain that may Diarrheal disease continues to be an important lead to hypovolemic shock and dehydration, and cause of morbidity and mortality among young chil- subsequently death in severe cases [1]. Worldwide, Received：December 27, 2017, Revised：January 16, 2018, Accepted：January 19, 2018 Corresponding author: Hadi Fakih, Department of Pediatrics, Faculty of Medical Sciences, Lebanese University, Rafic Hariri University Campus, Hadas, Beirut, Lebanon. Tel: +961-3-912-686, Fax: +961-5463585, E-mail: [email protected] Copyright ⓒ 2018 by The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition This is an open­access article distributed under the terms of the Creative Commons Attribution Non­Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non­commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY & NUTRITION Ghassan Ghssein, et al：Identification of Main Causes of AGE in Lebanese Hospitalized Children gastroenteritis affects 3 to 5 billion children each to others Enteropathogens with data representing year, and accounts for 1.5 to 2.5 million deaths per mainly the population of Beirut [13]. Our SAGE year or 12% of all deaths among children less than 5 study prospectively enrolled and tested children ad- years of age [2]. In developed countries acute gastro- mitted for AGE to our hospital, Ragheb Harb Hospital enteritis (AGE) accounts for 300 deaths per year [2]. located in Nabatieh, south Lebanon, serving a pop- Globally, rotavirus (RV) is the most common etio- ulation of 350,000 habitants and about 35,000 Syrian logical agent for AGE [3]. Data from the coordinated refugees, during the summer period of 2014, to de- global network for RV surveillance of the World termine the prevalence and etiology of infectious Health Organization at 185 sentinel sites in 64 coun- gastroenteritis by using the routine available tests tries showed RV detection rates of 37-53% in chil- performed in our hospital laboratory. To our knowl- dren hospitalized with diarrhea in 2011 in regions of edge, few studies have been performed before and the world where vaccination has not been widely im- reported information regarding the percentage, the plemented [4] and RV is one of the most common age distribution, the risk factors and the protective causes of moderate to severe diarrhea during the first factors among hospitalized children with AGE in 2 years of life [5]. RV vaccination has been widely Southern’s Lebanon. available for children since 2006 [6] and is now rec- ommended worldwide, a growing body of evidence MATERIALS AND METHODS supports the benefits of its vaccination in the devel- oped and developing world [7]. Patients The protozoan intestinal parasite Entamoeba histo- During the summer of 2014, from July to mid of lytica is the agent of human amoebiasis. Infection by September, children were admitted to the pediatric this parasite is a major cause of morbidity and mor- department of a tertiary care private hospital located tality; it is also responsible for 50 million cases of in- in Toul, Nabatieh district, Lebanon. Children aged vasive disease [8] and about 70,000 deaths annually from 1 month to 10 years old were prospectively in- in the world [9]. Both E. histolytica and Giardia lamblia cluded in the study if the admission diagnosis was ei- have been listed by the National Institute of Health ther: AGE or diarrhea that was defined as the occur- as category B priority biodefense pathogens due to rence of three or more of watery stool of any nature their low infectious doses and potential for dissem- during the last twenty-four hours and in the absence ination through compromised food and water sup- of fever, vomiting, nausea, abdominal cramps or plies in the United States [10]. In developing coun- macroscopic blood and mucus in the stool. We ex- tries, parasitic diseases represent a social and eco- cluded patients with chronic diarrhea, malnutrition, nomic problem with more severe disease associated immunodeficiency or patients with multiple mal- with young age, malnutrition, and immunosuppr- formation. ession [11]. A trained healthcare person followed each case Despite the heavy burden of AGE especially in from the admission until discharge and collected data children below five years of age, improved pre- prospectively including: 1) Demographics: age, sex, vention is achievable. Personal and food hygiene, in- residency area, family size, nutrition, breast feeding cluding the use of clean water sources, are key meas- and the vaccination history to determine if any dose of ures to prevent transmission of these diseases [12]. the two RV vaccines (Rotarix from GlaxoSmithKline Breastfeeding, especially under 6 months of age, also Biologicals, Rixensart, Belgium; or Rotateq from effectively protects infants [12]. Merck Sharp & Dohme Corp, Whitestation, NJ, USA) A previous recent study in Lebanon showed an in- that are available and approved in Lebanon, was creasing prevalence of amoebiasis as the leading given. 2) Clinical data: the presence of fever, vomit- cause of hospitalized children for AGE in comparison ing, diarrhea, associated co-infections, urine output, www.pghn.org 177 Pediatr Gastroenterol Hepatol Nutr and the presence of blood or mucus in stool. 3) bodies against viral antigens. During the test, a Laboratory tests values: the results of stool analysis, pre-colored conjugate that had previously been dried microscopy for ova and parasites, the quick identi- was reacted with the sample. Afterwards, the mix- fication tests for adenovirus (CerTest; Biotec, ture moved forward on the membrane by means of Zaragoza, Spain) and RV (CerTest) and if available capillary action. The colored particles were replaced the results of stool culture, leukocytes counts, C-re- as the sample moved along the test membrane. If the active protein (CRP) level, electrolytes, blood sugar result was positive, the specific antibodies on the and transaminases level. 4) Also therapeutic inter- membrane captured the colored particles. ventions as intravenous bolus requirement, anti- biotics use, antiemetics and different antidiarrheic Statistical analysis agents used during the whole hospitalization length. Statistical analyses were conducted using IBM The study was approved by the ethical and scien- SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, tific committee of the Ragheb Harb Hospital (ethical USA). The level of significance was set at p＜0.05 for approval reference number 14/2014, date: 05/06/ all statistical analyses. Descriptive analyses were 2014). based on frequencies and percentages. The demo- graphic and the clinical characteristics among the Laboratory methods and studies five studied groups (E. histolytica group I, RV group II, Fresh stool samples were used to detect the prob- adenovirus group III, mixed group IV, unidentified able infectious agents. Stool samples were analyzed group V) were tabulated. Baseline comparisons be- within less than one hour after being sent to our lab- tween groups were performed using Kruskall-Wallis oratory, analysis included specific preparation and test for continuous variables.
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