Published online August 18, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. e541-e549 (doi:10.1542/peds.2008-0458)
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ARTICLE

Epidemiology of Highly Endemic Multiply Antibiotic-Resistant Shigellosis in Children in the Peruvian Amazon

Margaret Kosek, MDa,b, Pablo Peñataro Yori, MPHa,b, William K. Pan, DrPHa, Maribel Paredes Olortegui, BSb, Robert H. Gilman, MDa,b, Juan Perez, PEc, Cesar Banda Chavezb, Graciela Meza Sanchez, MDd, Rosa Burga, BSc and Eric Hall, PhDc

a Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
b Biomedical Research, AB PRISMA Morona 452, Iquitos, Peru
c Naval Medical Research Center Detachment, Lima, Peru
d Regional Health Department, Loreto, Peru

OBJECTIVE. Our goal was to estimate the impact of a Shigella vaccine in an area where shigellosis is endemic by characterizing the disease burden and antibiotic-resistance profiles of isolates and by determining the prevalence of Shigella flexneri serotypes.

PATIENTS AND METHODS. We conducted a 43-month-long prospective, community-based diarrheal disease surveillance in 442 children <72 months of age in the Peruvian Amazon between October 1, 2002, and April 15, 2006.

RESULTS. The incidence of diarrheal disease was 4.38 episodes per child-year. The incidence rate for shigellosis was 0.34 episodes per child-year in children <72 months of age and peaked in children between 12 and 23 months at 0.43 episodes per child-year. Maternal education at or beyond the primary grade level, piped water supply, weight-for-age z score, and improved water-storage practices were the most significant determinants of disease in this community with living conditions comparable to many rural areas in the developing world.

CONCLUSIONS. Children living in this region had a 20-fold higher rate of disease incidence detected by active surveillance as those recently estimated by passive detection. Most symptomatic disease was caused by S flexneri, although the diversity of serotypes will require a multivalent vaccine to have a significant impact on the burden of disease caused by shigellosis. Several other public health disease-control interventions targeted at water source and improved storage, nutritional interventions, and improved maternal education seem to have a greater impact than a univalent S flexneri 2a vaccine.

Key Words: antibiotic resistance • bacterial infections • diarrhea • nutrition • vaccines

Abbreviations: PCR—polymerase chain reaction • HAZ—height-for-age z score • WAZ—weight-for-age z score • WHZ—weight-for-age z score • GEE—generalized estimating equation • CI—confidence interval • QIC—Quasi-likelihood Information Criterion • IR—incidence rate • IRR—Incidence Rate Ratio

Accepted May 30, 2008.