Background Children under five bear the largest cholera burden. We therefore sought to identify modifiable risk factors among Bangladeshi children. Methodology/Principal Findings We used multivariate Poisson regression to assess risk factors for severe cholera among diarrheal patients presenting at hospitals in Matlab (rural) and Dhaka (urban), Bangladesh. Risk increased with age. Compared to those under one, rural and urban four-year-olds had adjusted risk ratios (aRR) of 4.17 (95% confidence interval (CI) 2.43–7.15) and 6.32 (95% CI: 4.63–8.63), respectively. Breastfeeding halved the risk in both rural (aRR = 0.49, 95% CI: 0.35–0.67) and urban (aRR = 0.51, 95% CI: 0.41–0.62) settings. Rural children’s risk decreased with maternal education (P-trend: <0.001) and increased among those with a family member with diarrhea in the past week (aRR = 1.61, 95% CI: 1.22–2.14) and those with prior vitamin A supplementation (aRR = 1.65, 95% CI: 1.12–2.43). Urban children whose mothers daily (aRR = 0.41, 95% CI: 0.21–0.79) or occasionally (aRR = 0.55, 95% CI: 0.36–0.84) read a newspaper experienced reduced risk. Urban children from households with incomes between 34–84 USD/month had a 30% increased risk compared to those from households with incomes >84 USD/month. Conclusion/Significance Increasing age, lower socioeconomic status, and lack of breastfeeding are key correlates of increased risk for cholera hospitalization among those under five in rural and urban Bangladesh. In addition, having a family member with diarrhea in the past week was associated with increased risk among rural children. Continued attention should be directed to the promotion of breastfeeding. Further research is needed to elucidate the relationship between maternal education and cholera risk. Renewed research regarding the use of chemoprophylaxis among family members of cholera cases may be warranted in rural endemic settings.
References
[1]
Ali M, Lopez AL, Ae You Y, Eun Kim Y, Sah B, et al. (2012) The global burden of cholera. Bull World Health Organ 90: 209–218 doi:10.2471/BLT.11.093427.
[2]
Mosley WH, Benenson AS, Barui R (1968) A serological survey for cholera antibodies in rural east Pakistan. 2. A comparison of antibody titres in the innunized and control populationd of a cholera-vaccine field-trial area and the relation of antibody titre to cholera case rate. Bull World Health Organ 38: 335–346.
[3]
Gunn Ra, Kimball aM, Pollard Ra, Feeley JC, Feldman Ra, et al. (1979) Bottle feeding as a risk factor for cholera in infants. Lancet 2: 730–732.
[4]
Clemens JD, Sack DA, Harris JR, Khan MR, Chakraborty J, et al. (1990) Breast feeding and the risk of severe cholera in rural Bangladeshi children. Am J Epidemiol 131: 400–411.
[5]
Qureshi K, M？lbak K, Sandstr？m A, Kofoed P-E, Rodrigues A, et al. (2006) Breast milk reduces the risk of illness in children of mothers with cholera: observations from an epidemic of cholera in Guinea-Bissau. Pediatr Infect Dis J 25: 1163–1166 doi:10.1097/01.inf.0000246977.58697.a5.
[6]
Guerrant RL, Kirchhoff L V, Shields DS, Nations MK, Leslie J, et al. (1983) Prospective study of diarrheal illnesses in northeastern Brazil: patterns of disease, nutritional impact, etiologies, and risk factors. J Infect Dis 148: 986–997.
[7]
Strand T a, Sharma PR, Gjessing HK, Ulak M, Chandyo RK, et al. (2012) Risk factors for extended duration of acute diarrhea in young children. PLoS ONE 7: e36436 doi:10.1371/journal.pone.0036436.
[8]
O’Reilly CE, Jaron P, Ochieng B, Nyaguara A, Tate JE, et al. (2012) Risk factors for death among children less than 5 years old hospitalized with diarrhea in rural western Kenya, 2005–2007: a cohort study. PLoS Med 9: e1001256 doi:10.1371/journal.pmed.1001256.
[9]
Mitra a K, Rahman MM, Fuchs GJ (2000) Risk factors and gender differentials for death among children hospitalized with diarrhoea in Bangladesh. J Health Popul Nutr 18: 151–156.
Kay B, Bopp C, Wells J (1994) Isolation and identification of Vibrio cholerae O1 from fecal specimens. In: Wachsmuth I, Blake P, Olsvik O, editors. Vibrio cholerae and cholera: molecular to global perspectives. Washington, DC: American Society for Microbiology Press. 3–25.
[12]
Schwartz BS, Harris JB, Khan AI, Larocque RC, Sack D a, et al. (2006) Diarrheal epidemics in Dhaka, Bangladesh, during three consecutive floods: 1988, 1998, and 2004. Am J Trop Med Hyg 74: 1067–1073.
[13]
WHO (1987) Programme for control of diarrhoeal diseases (CDD/83.3 Rev 1). Manual for laboratory investigation of acute enteric infections. Geneva: WHO.
[14]
XE Currency Table: Mid-market rates as of 2004-07-01 (n.d.). Available: http://www.xe.com/currencytables/?from=U？SD&date=2004-07-01. Accessed 2012 Nov 13.
[15]
WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (2010) Types of drinking-water sources and sanitation. Available: http://www.wssinfo.org/definitions-metho？ds/watsan-categories/. Accessed 2012 Oct 9.
[16]
Zou G (2004) A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 159: 702–706 doi:10.1093/aje/kwh090.
[17]
Greenland S (1995) Dose-response and trend analysis in epidemiology: alternatives to categorical analysis. Epidemiology 6: 356–365.
[18]
Haider R, Ashworth a, Kabir I, Huttly SR (2000) Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial [see commments]. Lancet 356: 1643–1647.
[19]
Glass RI, Becker S, Huq MI, Stoll BJ, Khan MU, et al. (1982) Endemic cholera in rural Bangladesh, 1966–1980. Am J Epidemiol 116: 959–970.
[20]
Giashuddin MS, Kabir M (2004) Duration of breast-feeding in Bangladesh. Indian J Med Res 119: 267–272.
[21]
Glass RI, Svennerholm AM, Stoll BJ, Khan MR, Hossain KM, et al. (1983) Protection against cholera in breast-fed children by antibodies in breast milk. N Engl J Med 308: 1389–1392 doi:10.1056/NEJM198306093082304.
[22]
Glass RI, Stoll BJ, Wyatt RG, Hoshino Y, Banu H, et al. (1986) Observations questioning a protective role for breast-feeding in severe rotavirus diarrhea. Acta Paediatr Scand 75: 713–718.
[23]
Levine RJ, Khan MR, D’Souza S, Nalin DR (1976) Failure of sanitary wells to protect against cholera and other diarrhoeas in Bangladesh. Lancet 2: 86–89.
[24]
Chowdhury F, Khan AI, Harris JB, LaRocque RC, Chowdhury MI, et al. (2008) A comparison of clinical and immunologic features in children and older patients hospitalized with severe cholera in Bangladesh. Pediatr Infect Dis J 27: 986–992 doi:10.1097/INF.0b013e3181783adf.
[25]
Palmer DL, Koster FT, Alam a K, Islam MR (1976) Nutritional status: a determinant of severity of diarrhea in patients with cholera. J Infect Dis 134: 8–14.
[26]
Rahman KM, Duggal P, Harris JB, Saha SK, Streatfield PK, et al. (2009) Familial aggregation of Vibrio cholerae-associated infection in Matlab, Bangladesh. J Health Popul Nutr 27: 733–738.
[27]
Glass RI, Holmgren J, Haley CE, Khan MR, Svennerholm AM, et al. (1985) Predisposition for cholera of individuals with O blood group. Possible evolutionary significance. Am J Epidemiol 121: 791–796.
[28]
Giebultowicz S, Ali M, Yunus M, Emch M (2011) A comparison of spatial and social clustering of cholera in Matlab, Bangladesh. Health Place 17: 490–497 doi:10.1016/j.healthplace.2010.12.004.
[29]
Blake PA, Ramos S, MacDonald KL, Rassi V, Gomes TA, et al. (1993) Pathogen-specific risk factors and protective factors for acute diarrheal disease in urban Brazilian infants. J Infect Dis 167: 627–632.
[30]
Rowe PC, Orrbine E (1994) Epidemic Escherichia coil O157: H7 gastroenteritis and hemolytic-uremic syndrome in a Canadian Inuit community: Intestinal illness in family members as a risk factor: 1–6.
[31]
Ali M, Emch M, Park JK, Yunus M, Clemens J (2011) Natural cholera infection-derived immunity in an endemic setting. J Infect Dis 204: 912–918 doi:10.1093/infdis/jir416.
[32]
Harris JB, LaRocque RC, Chowdhury F, Khan AI, Logvinenko T, et al. (2008) Susceptibility to Vibrio cholerae infection in a cohort of household contacts of patients with cholera in Bangladesh. PLoS Negl Trop Dis 2: e221 doi:10.1371/journal.pntd.0000221.
[33]
Weil AA, Khan AI, Chowdhury F, Larocque RC, Faruque a SG, et al. (2009) Clinical outcomes in household contacts of patients with cholera in Bangladesh. Clin Infect Dis 49: 1473–1479 doi:10.1086/644779.
[34]
Mccarthy N, Giesecke J (1999) Case-case comparisons to study causation: 764–768.
[35]
Wilson N, Baker M, Edwards R, Simmons G (2008) Case-case analysis of enteric diseases with routine surveillance data: Potential use and example results. Epidemiol Perspect Innov 5: 6 doi:10.1186/1742-5573-5-6.
[36]
Reveiz L, Chapman E, Ramon-Pardo P, Koehlmoos TP, Cuervo LG, et al. (2011) Chemoprophylaxis in contacts of patients with cholera: systematic review and meta-analysis. PLoS ONE 6: e27060 doi:10.1371/journal.pone.0027060.
