Hospitalization and mortality among primarily nonbreastfed children during a large outbreak of diarrhea and malnutrition in Botswana, 2006.
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 country's 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.
Centers for Disease Control and Prevention, Global AIDS Program, 1600 Clifton Rd NE, Mailstop E-04, Atlanta, GA 30033, USA. tgc0@cdc.gov
Tracy L
TL
Creek
Andrea
A
Kim
Lydia
L
Lu
Anna
A
Bowen
Japhter
J
Masunge
Wences
W
Arvelo
Molly
M
Smit
Ondrej
O
Mach
Keitumetse
K
Legwaila
Catherine
C
Motswere
Laurel
L
Zaks
Thomas
T
Finkbeiner
Laura
L
Povinelli
Maruping
M
Maruping
Gibson
G
Ngwaru
Goitebetswe
G
Tebele
Cheryl
C
Bopp
Nancy
N
Puhr
Stephanie P
SP
Johnston
Alexandre J
AJ
Dasilva
Caryn
C
Bern
R S
RS
Beard
Margarett K
MK
Davis
D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use; D001902:Botswana / Q000453:epidemiology; D001942:Breast Feeding / Q000453:epidemiology* / Q000706:statistics & numerical data; D015362:Child Nutrition Disorders / Q000453:epidemiology* / Q000382:microbiology / Q000821:virology; D002675:Child, Preschool; D003906:Developing Countries; D003967:Diarrhea / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality*; D004196:Disease Outbreaks; D004755:Enterobacteriaceae / Q000302:isolation & purification; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D015497:HIV-1; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D041943:Infant Formula / Q000706:statistics & numerical data; D007226:Infant Mortality; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control / Q000706:statistics & numerical data; D009035:Mothers / Q000706:statistics & numerical data; D012307:Risk Factors
D000900:Anti-Bacterial Agents