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Now published in The Lancet

Heterogeneity in ETEC and Shigella Infections: A Subnational Approach Quantifying Risk, Mortality, Morbidity, and Stunting in 11 African Countries

46 Pages Posted: 21 Mar 2019

See all articles by Karoun Bagamian

Karoun Bagamian

University of Florida - Department of Environmental and Global Health; Bagamian Scientific Consulting

John D. Anderson

University of Florida - Department of Environmental and Global Health; Appalachian State University

Farzana Muhib

PATH

Oliver Cumming

London School of Hygiene & Tropical Medicine - Department of Disease Control

Lindsey A. Laytner

University of Florida - Department of Environmental and Global Health

Thomas F. Wierzba

PATH

Richard Rheingans

Appalachian State University

More...

Abstract

Background: Diarrhoea, a global cause of child mortality and morbidity, is linked to adverse consequences, including childhood stunting and death from other diseases. Few studies explore how diarrheal mortality varies subnationally, especially by aetiology, which is important for targeting investments and even fewer examine indirect effects of diarrheal morbidity on child mortality. We estimated the subnational distribution of mortality, morbidity, and childhood stunting attributable to ETEC (enterotoxigenic Escherichia coli [E. coli]) and Shigella infection in under-five-year-old children from 11 eastern and central African countries.

Methods: We combined proxy indicators of morbidity and mortality risk from the most recent Demographic and Health Surveys with published relative risks to estimate the potential distribution of diarrhoeal disease risk. To estimate subnational burden, we used country or WHO region-specific morbidity and mortality estimates and distributed them subnationally by indices that integrate relevant individual and household characteristics.

Findings: Characterizing ETEC and Shigella subnational estimates of indirect morbidity (infection-attributable stunting) and indirect mortality (stunting-related deaths from other infectious diseases) identified high risk areas that could be missed by traditional metrics. Including indirect ETEC and Shigella mortality in burden estimates resulted in some subnational areas having total ETEC and Shigella mortality rates 20 to 30% higher.

Interpretation: Understanding the indirect mortality and morbidity of diarrheal pathogens on a subnational level will strengthen disease control strategies and may have important implications for the relative impact and cost-effectiveness of new enteric vaccines. Because they rely on publicly available data, our methods could be employed for national planning.

Funding Statement: This work was funded by a grant to PATH from the Bill & Melinda Gates Foundation (OPP1112376).

Declaration of Interests: The authors declare no competing interests.

Keywords: Enterotoxigenic Escherichia coli, Shigella, diarrheal burden, subnational heterogeneity, stunting, indirect burden, child mortality, East Africa

Suggested Citation

Bagamian, Karoun and Anderson, John D. and Muhib, Farzana and Cumming, Oliver and Laytner, Lindsey A. and Wierzba, Thomas F. and Rheingans, Richard, Heterogeneity in ETEC and Shigella Infections: A Subnational Approach Quantifying Risk, Mortality, Morbidity, and Stunting in 11 African Countries (02/13/2019 22:19:04). Available at SSRN: https://ssrn.com/abstract=3335860 or http://dx.doi.org/10.2139/ssrn.3335860

Karoun Bagamian (Contact Author)

University of Florida - Department of Environmental and Global Health ( email )

PO Box 117165, 201 Stuzin Hall
Gainesville, FL 32610-0496
United States

Bagamian Scientific Consulting ( email )

Gainesville, FL
United States

John D. Anderson

University of Florida - Department of Environmental and Global Health ( email )

PO Box 117165, 201 Stuzin Hall
Gainesville, FL 32610-0496
United States

Appalachian State University ( email )

Boone, NC 28608
United States

Farzana Muhib

PATH ( email )

2201 Westlake Avenue, Suite 200
Seattle, WA 98121
United States

Oliver Cumming

London School of Hygiene & Tropical Medicine - Department of Disease Control ( email )

London, WC1E 7HT
United Kingdom

Lindsey A. Laytner

University of Florida - Department of Environmental and Global Health ( email )

PO Box 117165, 201 Stuzin Hall
Gainesville, FL 32610-0496
United States

Thomas F. Wierzba

PATH ( email )

2201 Westlake Avenue, Suite 200
Seattle, WA 98121
United States

Richard Rheingans

Appalachian State University ( email )

Boone, NC 28608
United States