Hospitalization and Mortality Among Primarily Nonbreastfed Children During a Large Outbreak of Diarrhea and Malnutrition in Botswana, 2006

• Published in: Journal of acquired immune deficiency syndromes (1999) Vol. 53; no. 1; pp. 14 - 19
• Main Authors: Creek, Tracy L, Kim, Andrea, Lu, Lydia, Bowen, Anna, Masunge, Japhter, Arvelo, Wences, Smit, Molly, Mach, Ondrej, Legwaila, Keitumetse, Motswere, Catherine, Zaks, Laurel, Finkbeiner, Thomas, Povinelli, Laura, Maruping, Maruping, Ngwaru, Gibson, Tebele, Goitebetswe, Bopp, Cheryl, Puhr, Nancy, Johnston, Stephanie P, Dasilva, Alexandre J, Bern, Caryn, Beard, R S, Davis, Margarett K
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins, Inc 01-01-2010; Lippincott Williams & Wilkins; Lippincott Williams & Wilkins Ovid Technologies
• Subjects: Anti-Bacterial Agents - adverse effects; Anti-Bacterial Agents - therapeutic use; Bacteriology; Biological and medical sciences; Black people; Botswana - epidemiology; Breast Feeding - epidemiology; Breast Feeding - statistics & numerical data; Child Nutrition Disorders - epidemiology; Child Nutrition Disorders - microbiology; Child Nutrition Disorders - virology; Child, Preschool; Children & youth; Cryptosporidium; Developing Countries; Diarrhea; Diarrhea - drug therapy; Diarrhea - microbiology; Diarrhea - mortality; Disease Outbreaks; Enterobacteriaceae - isolation & purification; Epidemics; Escherichia coli; Female; Follow-Up Studies; Fundamental and applied biological sciences. Psychology; HIV Infections - epidemiology; HIV Infections - microbiology; HIV Infections - transmission; HIV-1; Hospitalization; Hospitalization - statistics & numerical data; Human viral diseases; Humans; Infant; Infant Formula - statistics & numerical data; Infant Mortality; Infectious Disease Transmission, Vertical - prevention & control; Infectious Disease Transmission, Vertical - statistics & numerical data; Infectious diseases; Malnutrition; Medical sciences; Microbiology; Miscellaneous; Mortality; Mothers - statistics & numerical data; Risk Factors; Viral diseases; Virology; Botswana; Africa; Escherichia coli; HIV prevention; Prevention; Bacteria; Intestinal disease; Malnutrition; Child; Enterobacteriaceae; Human; Cryptosporidium; PMTCT; Nutrition disorder; Africa; Retroviridae; Diarrhea; Breast feeding; Lentivirus; water safety; Virus; HIV; Botswana; Digestive diseases; Vertical transmission; Human immunodeficiency virus; breastfeeding; replacement feeding; HIV vertical transmission
• ISSN: 1525-4135; 1944-7884
• DOI: 10.1097/QAI.0b013e3181bdf676

BACKGROUND:In 2006, a pediatric diarrhea outbreak occurred in Botswana, coinciding with heavy rains. Surveillance recorded a 3 times increase in cases and a 25 fold increase in deaths between January and March. Botswana has high HIV prevalence among pregnant women (33.4% in 2005), and an estimated 35% of all infants under the age of 6 months are not breastfed.
METHODS:We followed all children <5 years old with diarrhea in the countryʼs second largest referral hospital at the peak of the outbreak by chart review, interviewed mothers, and conducted laboratory testing for HIV and enteric pathogens.
RESULTS:Of 153 hospitalized children with diarrhea, 97% were <2 years old; 88% of these were not breastfeeding. HIV was diagnosed in 18% of children and 64% of mothers. Cryptosporidium and enteropathogenic Escherichia coli were common; many children had multiple pathogens. Severe acute malnutrition (kwashiorkor or marasmus) developed in 38 (25%) patients, and 33 (22%) died. Kwashiorkor increased risk for death (relative risk 2.0; P = 0.05); only one breastfeeding child died. Many children who died had been undersupplied with formula.
CONCLUSIONS:Most of the severe morbidity and mortality in this outbreak occurred in children who were HIV negative and not breastfed. Feeding and nutritional factors were the most important determinants of severe illness and death. Breastfeeding is critical to infant survival in the developing world, and support for breastfeeding among HIV-negative women, and HIV-positive women who cannot formula feed safely, may prevent further high-mortality outbreaks.