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.
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.
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.
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.
The Bill & Melinda Gates Foundation.
Copyright © 2013 Elsevier Ltd. All rights reserved.