title: High incidence of enteroaggregative Escherichia coli among food handlers in three areas of Kenya: a possible transmission route of travelers' diarrhea.
abstract: BACKGROUND
  Contaminated food and water are acknowledged vehicles for the transmission of travelers' diarrhea (TD). Importance of food handlers as reservoirs of enteroaggregative Escherichia coli (EAEC), enteropathogenic E coli (EPEC), and Shiga toxin-producing E coli (STEC) causing TD has not been clearly demonstrated.
  
  
  METHODS
  We undertook a 1-year prospective study to determine the presence and selected risk factors of carriage of EAEC, EPEC, and STEC by 1,399 food handlers working in tourist hotels in three popular tourist destinations of Kenya. Enterotoxigenic E coli (ETEC) was not sought in this study.
  
  
  RESULTS
  During the period April 2003 to May 2004, EAEC harboring the aggR gene were detected from 29 (2.1%) subjects and EPEC harboring the eaeA gene and STEC harboring the stx2 gene were detected from 11 (0.8%) and 2 (0.1%) of the study subjects, respectively. Mean age of subjects with EAEC was significantly lower (24.6 y) than the rest of the study population (28.2 y) (p < 0.05). Pit latrines usage was significantly associated with the isolation of EAEC (<0.001) but not with EPEC and STEC. Four of the 29 EAEC isolates were sensitive to all antibiotics tested, and 19 (65.5%) were multidrug resistant (MDR). Antibiotic resistance varied from 6.9% for cefuroxime to 72.4% for co-trimoxazole. Six EPEC isolates (6/13, 46.2%) showed multidrug resistance. Cluster analysis of the pulsed-field gel electrophoresis (PFGE) profiles showed that the EAEC isolates belonged to two clonally unrelated genotypes.
  
  
  CONCLUSIONS
  We conclude that food handlers working in tourist hotels are important carriers of EAEC that could cause TD and a high proportion of the EAEC are MDR. The isolation of MDR EAEC from food handlers working in tourist hotels is of potential public health importance. There is a need for a study employing molecular methods including PFGE to examine carriage of similar pathogens in food handlers, processed foods, and travelers consuming the food who develop diarrhea.
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya. joundo@ke.cdc.gov
authors.forename: Joseph O
authors.initials: JO
authors.lastname: Oundo
authors.forename: Samuel M
authors.initials: SM
authors.lastname: Kariuki
authors.forename: Hamadi I
authors.initials: HI
authors.lastname: Boga
authors.forename: Faith W
authors.initials: FW
authors.lastname: Muli
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Iijima
mesh_terms: D000293:Adolescent; D000328:Adult; D003967:Diarrhea / Q000453:epidemiology*; D024881:Drug Resistance, Bacterial; D016521:Electrophoresis, Gel, Pulsed-Field; D054308:Enteropathogenic Escherichia coli; D004927:Escherichia coli Infections / Q000188:drug therapy / Q000453:epidemiology*; D005243:Feces / Q000382:microbiology; D005260:Female; D005511:Food Handling; D006801:Humans; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009784:Occupational Diseases / Q000453:epidemiology*; D054323:Shiga-Toxigenic Escherichia coli; D014195:Travel