title: Estimating diarrheal illness and deaths attributable to Shigellae and enterotoxigenic Escherichia coli among older children, adolescents, and adults in South Asia and Africa.
abstract: BACKGROUND
  While Shigellae and strains of enterotoxigenic Escherichia coli (ETEC) are important causes of diarrhea-associated morbidity and mortality among infants and young children (<5 years of age), their health impact in older age groups is unclear. We sought to quantify the overall burden of shigellosis and ETEC diarrhea among older children, adolescents, and adults in Africa and South Asia, the two regions with the highest levels of diarrhea-related morbidity and mortality worldwide.
  
  
  METHODS
  We employed two distinct methodological approaches to estimate the burden of diarrhea due to Shigellae and ETEC among persons ≥ 5 years of age in the WHO regions of South Asia (SEAR) and Africa (AFR). Under method 1, we conducted a systematic review to identify the median proportion of total deaths due to diarrhea and then applied this figure to the number of all-cause deaths that occurred in 2010 among this age group. To estimate the total number of diarrhea deaths attributable to Shigellae and ETEC, we subsequently applied previously published estimates of the median percentage of diarrhea hospitalizations due to Shigellae and ETEC to the estimated number of diarrhea deaths. For method 2, we applied previously published incidence rates to 2010 population figures and estimated the total number of episodes due to Shigellae and ETEC using published estimates of the average proportion of pathogen-positive outpatients from studies of >4 pathogens. We then estimated the number of pathogen-specific deaths by determining the number of hospitalized patients and applying the case-fatality rate.
  
  
  RESULTS
  By method 1, there were 19,451 deaths due to Shigellae and 42,973 due to ETEC in AFR, and 20,691 due to Shigellae and 45,713 due to ETEC in SEAR in 2010. By method 2, there were 15.0 million ETEC episodes and 30.4 million episodes due to Shigellae in AFR, and 28.7 million episodes due to ETEC and 58.1 million episodes due to Shigellae in SEAR in 2010. We were unable to identify published case-fatality rates for ETEC and thus could only estimate Shigellae-related deaths using method 2, by which there were 5,308 and 10,158 Shigellae-related deaths in AFR and SEAR in 2010, respectively.
  
  
  CONCLUSIONS
  Methods 1 and 2 underscore the importance of Shigellae and ETEC as major causes of morbidity and mortality among older children, adolescents, and adults in AFR and SEAR. Understanding the epidemiology of these pathogens is imperative for the development and use of future vaccines and other preventative interventions.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Laura M
authors.initials: LM
authors.lastname: Lamberti
authors.affiliation: PATH, Washington, D.C., United States of America.
authors.forename: A Louis
authors.initials: AL
authors.lastname: Bourgeois
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Christa L
authors.initials: CL
authors.lastname: Fischer Walker
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Black
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: David
authors.initials: D
authors.lastname: Sack
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa / Q000453:epidemiology; D001208:Asia / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D004405:Dysentery, Bacillary / Q000453:epidemiology / Q000401:mortality; D054307:Enterotoxigenic Escherichia coli; D004927:Escherichia coli Infections / Q000453:epidemiology / Q000401:mortality; D006801:Humans; D008875:Middle Aged; D012760:Shigella; D055815:Young Adult