title: Determinants and Impact of Giardia Infection in the First 2 Years of Life in the MAL-ED Birth Cohort.
abstract: Giardia are among the most common enteropathogens detected in children in low-resource settings. We describe here the epidemiology of infection with Giardia in the first 2 years of life in the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED), a multisite birth-cohort study.
  From 2089 children, 34916 stool samples collected during monthly surveillance and episodes of diarrhea were tested for Giardia using an enzyme immunoassay. We quantified the risk of Giardia detection, identified risk factors, and assessed the associations with micronutrients, markers of gut inflammation and permeability, diarrhea, and growth using multivariable linear regression.
  The incidence of at least 1 Giardia detection varied according to site (range, 37.7%-96.4%) and was higher in the second year of life. Exclusive breastfeeding (HR for first Giardia detection in a monthly surveillance stool sample, 0.46 [95% confidence interval (CI), 0.28-0.75]), higher socioeconomic status (HR, 0.74 [95% CI, 0.56-0.97]), and recent metronidazole treatment (risk ratio for any surveillance stool detection, 0.69 [95% CI, 0.56-0.84]) were protective. Persistence of Giardia (consecutive detections) in the first 6 months of life was associated with reduced subsequent diarrheal rates in Naushahro Feroze, Pakistan but not at any other site. Giardia detection was also associated with an increased lactulose/mannitol ratio. Persistence of Giardia before 6 months of age was associated with a -0.29 (95% CI, -0.53 to -0.05) deficit in weight-for-age z score and -0.29 (95% CI, -0.64 to 0.07) deficit in length-for-age z score at 2 years.
  Infection with Giardia occurred across epidemiological contexts, and repeated detections in 40% of the children suggest that persistent infections were common. Early persistent infection with Giardia, independent of diarrhea, might contribute to intestinal permeability and stunted growth.
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, Charlottesville.
authors.forename: Elizabeth T
authors.initials: ET
authors.lastname: Rogawski
authors.affiliation: Division of Infectious Diseases, University of North Carolina-Chapel Hill.
authors.forename: Luther A
authors.initials: LA
authors.lastname: Bartelt
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, Charlottesville.
authors.forename: James A
authors.initials: JA
authors.lastname: Platts-Mills
authors.affiliation: Fogarty International Center, National Institutes of Health, Bethesda, Maryland.
authors.forename: Jessica C
authors.initials: JC
authors.lastname: Seidman
authors.affiliation: University of Venda, Thohoyandou, South Africa.
authors.forename: Amidou
authors.initials: A
authors.lastname: Samie
authors.affiliation: Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Havt
authors.affiliation: Christian Medical College, Vellore, India.
authors.forename: Sudhir
authors.initials: S
authors.lastname: Babji
authors.affiliation: Asociación Benéfica PRISMA, Iquitos, Peru.
authors.forename: Dixner Rengifo
authors.initials: DR
authors.lastname: Trigoso
authors.affiliation: Aga Khan University, Karachi, Pakistan.
authors.forename: Shahida
authors.initials: S
authors.lastname: Qureshi
authors.affiliation: Aga Khan University, Karachi, Pakistan.
authors.forename: Sadia
authors.initials: S
authors.lastname: Shakoor
authors.affiliation: International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors.forename: Rashidul
authors.initials: R
authors.lastname: Haque
authors.affiliation: Haydom Lutheran Hospital, Haydom, Tanzania.
authors.forename: Estomih
authors.initials: E
authors.lastname: Mduma
authors.affiliation: Walter Reed AFRIMS Research Unit Nepal, Kathmandu, Nepal.
authors.forename: Samita
authors.initials: S
authors.lastname: Bajracharya
authors.affiliation: International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors.forename: S M Abdul
authors.initials: SMA
authors.lastname: Gaffar
authors.affiliation: Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil.
authors.forename: Aldo A M
authors.initials: AAM
authors.lastname: Lima
authors.affiliation: Christian Medical College, Vellore, India.
authors.forename: Gagandeep
authors.initials: G
authors.lastname: Kang
authors.affiliation: Asociación Benéfica PRISMA, Iquitos, Peru.|Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Margaret N
authors.initials: MN
authors.lastname: Kosek
authors.affiliation: International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors.forename: Tahmeed
authors.initials: T
authors.lastname: Ahmed
authors.affiliation: Haukeland University Hospital, Bergen, Norway.
authors.forename: Erling
authors.initials: E
authors.lastname: Svensen
authors.affiliation: Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand; and.
authors.forename: Carl
authors.initials: C
authors.lastname: Mason
authors.affiliation: Aga Khan University, Karachi, Pakistan.
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.affiliation: Foundation for the National Institutes of Health, Bethesda, Maryland.
authors.forename: Dennis R
authors.initials: DR
authors.lastname: Lang
authors.affiliation: Foundation for the National Institutes of Health, Bethesda, Maryland.
authors.forename: Michael
authors.initials: M
authors.lastname: Gottlieb
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, Charlottesville.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Guerrant
authors.affiliation: Division of Infectious Diseases and International Health, University of Virginia, Charlottesville.
authors.forename: Eric R
authors.initials: ER
authors.lastname: Houpt
authors.affiliation: University of Venda, Thohoyandou, South Africa.
authors.forename: Pascal O
authors.initials: PO
authors.lastname: Bessong
mesh_terms: D000367:Age Factors; D001942:Breast Feeding / Q000706:statistics & numerical data; D002675:Child, Preschool; D003906:Developing Countries / Q000706:statistics & numerical data; D003967:Diarrhea / Q000209:etiology; D005243:Feces / Q000469:parasitology; D005260:Female; D005873:Giardiasis / Q000150:complications / Q000453:epidemiology* / Q000209:etiology; D006130:Growth Disorders / Q000209:etiology; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015995:Prevalence; D012307:Risk Factors; D012959:Socioeconomic Factors; D013851:Thinness / Q000209:etiology
keywords: Giardia; children; growth; intestinal permeability; risk factors.