Aetiology of Acute Gastro-Enteritis in Children at Saint Camille Medical Centre, Ouagadougou, Burkina Faso
The present study aims at identifying the infectious
agents responsible for child Acute Gastro-Enteritis (AGE) in Ouagadougou.
From May 5 2006 to June 22 2008, 648 children aged from 2 to 41 months,
with at least an average of 3 loose stools per day have been enrolled
for coproculture, parasitology and virology test. Among them, 34 (5.25%)
were HIV seropositive. A single sample of faeces from each child was used
to identify enteropathogens. An infectious aetiology was identified in
41.20% of cases. The pathogenic agents detected as responsible for the
AGE are: Rotavirus 21.1%; Adenovirus 1.9%; Giardia 7.6% Entamoeba;
1.08%; entero-pathogenic E. coli 41.7%; Salmonella 3.40%; Shigella
1.85% and Yersinia 1.70%. Conclusion: Therefore, these AGE etiologic agents
constitute a problem of public health in Burkina Faso. Their control for
the child would require: (1) a regular paediatric and clinical follow
up; (2) health education of the population for food hygiene; (3) and in
case of absence of HIV infection in the mother, a promotion of exclusive
breast-feeding up to the age of 4 months.
to cite this article:
J. Simpore, D. Ouermi, D. Ilboudo, A. Kabre, B. Zeba, V. Pietra, S. Pignatelli, J.B. Nikiema, G.B. Kabre, S. Caligaris, F. Schumacher and F. Castelli, 2009. Aetiology of Acute Gastro-Enteritis in Children at Saint Camille Medical Centre, Ouagadougou, Burkina Faso. Pakistan Journal of Biological Sciences, 12: 258-263.
Burkina Faso is a West African country bordering with Mali in the North, Niger
in the East and Cote dIvoire, Ghana, Togo and Benin in the South. One
of the major problems in this country is emaciation in children less than 5
years old, caused by acute gastro-enteritis (AGE), which generally entails periods
of dehydrating diarrhoea and malnutrition (Simpore et
al., 2005; Pignatelli et al., 2000).
AGE is responsible for 30 to 50% of the cases of acute paediatric diarrhoea
in poor countries (Giordano et al., 2001). Acute
diarrhoea constitutes one of the major causes of child morbidity and mortality
and accounts for an estimated yearly 2 million deaths among children less than
5 years old in the world (Orlandi et al., 2006;
Luz et al., 2005). About 130 million children
suffer from diarrhoea caused by Rotavirus (RV) every year and among them, 18
million develop moderate to acute dehydration, resulting in 418.000 to 520.000
deaths (Luz et al., 2005; Ouermi
et al., 2007). In Burkina Faso, the incidence of diarrhoea is 6 to
8 episodes per child per year among children less than 5 years old. (Ouermi
et al., 2007; Sanou et al., 1999).
The immediate causes are often infectious and include a variety of pathogenic
micro organisms, namely viruses, bacteria and protozoa (Giordano
et al., 2001). Nowadays, paediatric infections in developing countries
are increasing due to: (1) lack in alimentary hygiene for children who crawl
on the ground, drink dirty water and eat sand (Ouermi et
al., 2007). (2) HIV/AIDS infection, which implies the lowering of the
immune system, favouring various co-infections (Mbaye et
al., 2005) and (3) absence of hygiene in public hospitals, causing transversal
transmission of pathogenic agents and nosocomial infections.
The objective of the present study was to identify causative agents of
AGE and to assess their prevalence.
MATERIALS AND METHODS
From May 5, 2006 to June 22, 2008, 648 samples of faeces were collected
from children suffering from acute diarrhoea, with the occurrence of at
least 3 loose or liquid faeces or stools per day, with or without vomiting.
The specimen were cultured and analysed in the biomedical laboratory at
Saint Camille, Ouagadougou. Among them, 34 (5.25%) were HIV seropositive.
Most of these children came from poor peripheral neighbourhoods of Ouagadougou,
where food hygiene is not well practiced. They were all followed up by
our ambulatory team and a questionnaire was filled up during the medical
consultation, specifying the age and sex. The same day, anthropometric
measures such as weight and height were taken. For each sample of faeces,
three types of testing were carried out:
||Detection of intestinal parasites: The faeces were
collected early in the morning in plastic bags and each sample was submitted
to a microscope test (to detect the presence of blood, mucus or adult worms)
within 30 min after each emission of faeces. The standard parasitological
test included a direct analysis of fresh stools, a technique of concentration
type WILLIS and the use of LUGOL E. histolytica and Giardia intestinalis
cysts identification (Arslan et al., 2008)
||Coproculture: Each sample was cultured in a specific
medium in conformity with the current norms, such as the salmonella-shigella
medium (SS) and the Thiosulfate Citrate Bile Sucrose medium (TCBS) to isolate
V. cholera. The EMB medium was used for the detection of E. coli
EPEC for children and gelose Yiersinia CIN to isolate Yiersinia enterocolitica.
The identification of bacteria was carried out by an observation of colonies,
then morphological features were observed at the microscope and results
were confirmed by the API 20 system (bioMérieux, France) (Dortet
et al., 2006)
||Research on viruses was carried out with Adeno-Strip and Rota-Strip
protocols of tests of inter medial srl. Via A Genovesi 13-80010 Villaricca
NA, which are kits that enable a detection of Adenovirus enteritis (ADE)
and Rotavirus (RV) in faeces with the use of an immunochromatographic technique
on membrane (Ouermi et al., 2007)
The HIV test: after their mothers knowledgeable consent, 5 mL
of blood was taken from each child suffering from AGE and put into an EDTA tube
for the HIV serology test. For this analysis, two quick tests were sequentially
used: Determine and Genie-II to detect HIV 1 and HIV 2, as previously described
by Koblavi-Deme et al. (2001). After two quick
tests with discordant results, a third test was used. In such cases the samples
were tested with the ELISA technique, using the Abbott-IMX System (Abbott laboratories,
N. Chicago), in order to confirm or exclude a result of HIV infection.
In addition, childrens anthropometric measures (weight and height) were
taken to determine their state of dehydration and malnutrition by Z-scores with
the use of international references on the concerned population defined by the
US National Center for Health Statistics (NCHS) (Simpore
et al., 2005). The children were then classified according to the
Z-score (or SD-score: Standard Deviation score). This system of classification
according to Z-score recommended by the WHO and UNICEF services, uses weight/height
(WHZ) nutritional indices, weight/age (WAZ) and this is done according to the
following criteria: Z-score inferior to -3: corresponds to acute malnutrition;
Z-score between -3 and -2: means a moderate malnutrition and finally a Z-score
superior to -2 corresponds to a good nutrition (Simpore
et al., 2005).
Ethical aspect: This study was approved by the Ethical Committee
of Saint Camille Medical Centre. We also got free and knowledgeable oral
consent of childrens mothers.
Data processing: Statistic analyses carried out with software
Epi-info version 6 and SPSS version 12. The value of p ≤ 0.05 has been
considered as significant.
The studies were effected on 648 children suffering from AGE and among
them 34 were infected with HIV/AIDS. Table 1 shows the
classification and anthropometrical features of the concerned population
through a study according to age. Let us specify that in our sample there
was a significant statistical difference between the two sexes as for
averages in age (p<0.001).
Because of the severe dehydrating diarrhoea provoked by AGE, among the
studied children, 405 over 648 (62.50%) presented an insufficient weight
for their age and 335 children over 648 (51.70%) had an insufficient weight
for their height (Table 2).
||Averages of age, weight and height of the children according
to the total number of each age class
||No. of children (648) per Z-score value: height/age
(HAZ), weight/height (WHZ) and weight/age (WAZ), correlated with nutritional
|| Frequency of rotavirus, adenovirus, HIV and intestinal
|NS: Not significant, Rotavirus 1→ 2: p = 0.380
(NS); 1→ 3: p = 0.030; 1→ 4: p = 0.013; 2→ 3: p = 0.111
(NS); 2→ 4: p = 0.028; 3→ 4: p = 0.297 SNS
|| Serology of HIV-1 correlated with various co-infections
and anthropometric parameters
|NS: Not significant
The biological test enabled us to identify the aetiological agents of
AGE: parasites (Giardia intestinalis, Entamoeba histolytica),
bacteria (Escherichia coli EPEC, Salmonella, Shigella,
Yersinia) and viruses (Rotavirus and Adenovirus) (Table
3). Other parasites (Hyménolopis nana, Ténia
intestinalis, Strongyloids stercoralis) and bacteria (Klebsiella
pneumoniae and Shigella flexneri) non inductive pathogens of
AGE have been isolated. Table 4 shows the HIV-1 serology
association with various co-infections.
Through this study, we notice that children from 2 to 10 months of age constitute
the most representative age class in the sample with a ratio of 292/648 (Table
1). Sanou et al. (1999) in their study, carried
out at Yalgado Ouédraogo Hospital in Burkina Faso and Orlandi
et al. (2006) in their research carried out at Porto Velho in Brazil,
have respectively presented frequencies of diarrhoea of 55.7 and 53.3% for children
of this same age class. During the first months of the childs life, the
variety of the repertory of antibodies against infectious agents is limited
(Weitkamp et al., 2003). It is precisely at this
period that the childs own immunity develops progressively and that a
lowering of maternal antibodies occurs. It is at the interface between the development
of these anti-bodies and the loss of maternal immunity that the crucial moment
of the foster childs immunological vulnerability is situated (Sanou
et al., 1999). In rural areas as well as in town, when the infant
starts crawling on hands and knees, he eats some earth, touches objects around
him and puts everything into his mouth: it is the period of high contact with
pathogenous microorganisms (Ouermi et al., 2007).
In this vision, there is a strong link between overcrowding, poverty and high
prevalence of diarrhoea in African cities. On the other hand, for the age class
between 11 and 20 months, the frequency of diarrhoea could be related to contaminants
in water and in solid foods progressively introduced in the childs diet,
since breastfeeding in Burkina Faso is almost never exclusive.
Virology: on the entire sample, we could identify 137 (21.1%) seropositive
children with the RV test (Table 4). Our values are superior
to those obtained, respectively by Sanou et al. (1999)
in Ouagadougou (14.4%), Olesen et al. (2005)
in Danemark (13.2%) and Cardoso et al. (2003)
at Goiânia (in Brazil) (14.4%). However, similar rates have been obtained
by Mala in Burkina Faso (1993) (21.5%) and Ouermi et
al. (2007) in Ouagadougou (22.7%) as well as Fodha
et al. (2006) in Tunisia (20.0%). The same value remains inferior
to those of Kim et al. (1990) in Korea (68%),
of Giordano et al. (2001) at Cordoba in Argentina
(35.3%) and Armah et al. (2003) in Ghana (40.5%).
These data show that RV has an incidence which varies from one country to another
and inside the same country, but they remain the principal etiologic agent in
viral AGE everywhere in the world (Gerba et al.,
1996). In our study, the frequency of RV infection significantly decreases
according to age classes 2-10 months → 21-30 months (p = 0.030); 2-10 months
→ 31-41 months (p = 0.013) and from 11-20 months → 31-41 months (p
= 0.028) (Table 3). In fact, according to Cardoso
et al. (2003), studies the rate of Rotaviruses was high for less
than 12 months old children compared to children who are 24 months old and sharply
decreases after 24 months. The frequency of AdE in our sample is 1.9% (12/648)
(Table 4). This rate is similar to that obtained by Giordano
et al. (2001) at Cordoba in Argentina (1.5%), but it is inferior
to the rate recorded by Jarecki-Khan et al. (1993)
in Bangladesh which is 2.8% and that of Fodha et al.
(2006) in Tunisia (6%). In fact, AdE are mainly acknowledged as important
aetiological agents of infant viral gastroenteritis in countries with a temperate
climate (Ouermi et al., 2007; Cruz et al.,
1990), which could account for the low rate obtained in Burkina Faso, a
country of tropical climate.
Parasitology: In addition to the pathological agents showed in evidence,
intestinal parasites are also recorded as etiologic agents of AGE: 49/648 Giardia
intestinalis; 7/648 Entamoeba histolytica. Moreover, we could isolate
parasites such as Trichomonas intestinalis (25/648); Hymenolepis nana
(16/648); Strongyloïdae stercoralis (13/648) that usually do not
induce diarrhoea. However, we have not identified Protozoa and Helminths in
children under 10 months of life. Among the protozoa identified during our study,
Giardia intestinalis was the most frequent parasite (7.56%). The giardia
are parasites with cysts and their mode of dissemination occurs easily when
drinking water or eating dirty vegetables. Nematian et
al. (2004) have recorded the same facts at Tehran (Iran) with a frequency
Bacteriology: Among the 648 samples of faeces taken from patients suffering
from diarrhoea and analysed in coproculture within the laboratory of Saint Camille,
we could identify 267/648 (41.20%) bacterio-positive cultures. At the level
of isolated bacteria which cause AGE, the E. coli EPEC have the highest
frequency (27/72: 37.5%). This prevalence can be compared to other results in
Ouagadougou by Bonfiglio et al. 2002 (35.0%)
which is superior to the one found by Lin et al.
(2006) (29.7%) by Simpore et al. (2008) (27,6%),
but inferior to those identified by Abdullah et al.
(2005) (66.7%) and Mohanna et al. (2005)
(66.3%). This predominance confirms that the pathogenous E. coli remain
the major causes of child bacterial diarrhoeas in tropical developing countries
(Alikhani et al., 2006; Moyo
et al., 2007).
Co-infections HIV: In this study, we emphasize that there is a
significant statistic difference between HIV positive and HIV negative
as regards co-infections with RV (p = 0.012), Salmonella sp. (p<0.001)
and E. coli EPEC (p<0.001), which means that children that are
affected with HIV are the most co-infected with these pathogens because
of their immune deficiency. Similarly, children with HIV positive have
more AGE and lose more weight than children with HIV negative (WAZ: p
= 0.027; WHZ: p = 0.05).
From this study, we notice that: AGE with viral, parasitic or bacterial
origin are very important among the pathologies of the less than 60 months
old child; many children, irrespective of their HIV serology suffer from
diarrhoea and malnutrition and are dehydrated. Any time, HIV seropositive
or seronegative children meet high risks of viral, bacterial and parasitic
co-infections. Therefore, a control of AGE would need a regular clinical
follow up of the children, a veterinary surveillance of the bird and bovine
channel as well as an adequate education of young women at procreative
age in hygiene, at the levels of Nutritional, Educational and Recuperation
Centres (CREN) in Burkina Faso. These types of preventive and training
measures could contribute to a significant reduction in the prevalence
of AGE, which causes many deaths among children in developing countries.
The researchers are grateful to the staff of Saint Camille laboratory,
Ouagadougou. In particular, the skilful and patient collaboration of Mr.
Oscar Zoungrana, Mrs. Fatoumata Nana, Mr. Bakamba Robert, Mr. Hermann
Somda and Mrs. Justine Yara. They are deeply grateful to the Italian Episcopal
Conference (C.E.I) and to the RADIM House, Roma, Italy and Doctor Luigi
SPARANO for the financial support. They are deeply grateful to Mrs Ouedraogo
Cecile for the translation in English of the manuscript.
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