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Aetiology and Epidemiology of Sever Infantile Diarrhoea in Baghdad, Iraq 366 (B) Frequency of isolation of enteric pathogens The frequency of isolation of various enteric pathogens from diarrhoeal patients enrolled in the prospective study was compared with the control as shown in Table (5) Table 5: Prevalence of enteric pathogens isolated Aetiology Number of patients with pathogens isolated Number of healthy control with pathogens isolated Number Percentage Number Percentage ٌRotavirus 59 29.5 0 0 EPEC 25 12.5 1 1 ETEC 5 2.5 0 0 Campylobacter 14 7 4 4 Salmonella 11 5.5 5 5 Shigella 6 3 0 0 Giardia 6 3 3 3 H.histolytica 4 2 2 2 Mixed 9 4.5 0 0 Unidentified 61 30.5 85 85 Total 200 100 100 100 Human rotavirus and bacterial pathogens were detected in 29.5% and 35% of the 200 episodes of diarrhea in the study group of infants respectively. Rotavirus was the most frequently isolated pathogen (29.5%) which was detected by Enzyme linked immunosorbent assay (ELISA) test and confirmed by ELISA-blocking assay, followed by EPEC (12.5) and Campylobacter jejune (7%). Salmonella was isolated in 5.5% then Shigella (3%), G. lambelia in 3%, ETEC 2.5% and E. histolytica in 2% respectively. Diarrhoea with unknown aetiology accounted for 30.5% of the episodes (Figure 5). percentage 35 30 25 20 15 10 5 0 EPEC = enteropathogenic E.coli Camp = Campylobacter Salmon = Salmonella Shig = Shigella Giard = Giardia ETEC = enterotoxigenic E. coli E.hist = E.histolytica 30.5 29.5 no ne Ro tavirus Figure 5: Percentage of pathogens isolated 12.5 EP EC 7 Camp A symptomatic carriage of Salmonella ,Campylobacter, EPEC, Giardia, Entameba were detected in 5%,4%, 1%, 3%, 2%, of healthy infants respectively. Rotavirus was not detected in asymptomatic infants. Asymptomatic carriage of ETEC and Shigella was not detected 5.5 Salmon Shig 3 3 2.5 2 Giard ET EC E.hist East West North
367 E. N. Al-kaissi, M. Makki and M. Al- Khoja No pathogens were isolated for 30.5% of diarrhoeal cases; some of these cases may be caused by other enteric viruses or parasites which were not investigated. Discussion and Conclusion Gastroenteritis in children is a common reason for visits to family physicians. Most cases of gastroenteritis have a viral etiology and are self-limited. However, more severe or prolonged cases of gastroenteritis can result in dehydration with significant morbidity and mortality. This is often the scenario in third-world countries, where gastroenteritis results in 3 million deaths annually. Some problems still exist in Iraq in educating the public and professional on the new concepts of diarrhoeal management as oral rehydration and continued feeding. This has been reflected in the presence of a large number of parents who refused or were reluctant to accept this approach of therapy (Table 4). Most children with gastroenteritis can be treated with physiologically balanced oral rehydration solutions [15]. In children who are hypovolemic, lethargic and estimated to be more than 5 percent dehydrated, initial treatment with intravenous boluses of isotonic saline or Ringer's lactate may be required. Children with severe diarrhea need nutrition to restore digestive function and, generally, food should not be withheld [15]. Prevalence of diarrhea during summer season is a common feature of tropical and subtropical countries and occurred more in infants under one year of age (Figure 1) similar findings were reported by [26]. Others reported that there is marked seasonal variation in occurrence of infection with peaks of incidence during summer and autumn [21]. The association of faecal leucocytes with organism known to penetrate intestinal mucosa such as Shigella species and EPEC was noted in this work. Similar findings were reported by others [27, 28, and 29], so the importance of direct stool examination of patient with diarrhea was reemphasis in this work. The maximum incidence (45%) of gastroenteritis occurs in patients with 7-12 month of age, the same results were reported by Ballal and Shivanada in 2002[30]. Diarrhea caused by Rotavirus was detected in 29.5% of the diarrhoeal children, the infection exhibited a marked seasonal distribution, with most of the cases occurring during the summer, and other similar studies undergone in Basrah (southern part of Iraq) have reported that Rotavirus admissions and isolation rates were highest during late winter. Khetsuriani, and Parashar reported in 2002[31] that in temperate climates, rotavirus disease predominantly occurs during the fall and winter months, a study from Japan showed that, unlike in children, rotavirus diarrhea in adults did not show significant winter seasonality, in the United States, rotavirus activity peaks in the Southwest in autumn (October through December) and migrates across the continent, peaking in the Northeast during spring (March through May), in tropical settings, rotavirus disease occurs year-round [31].These may be due to weather and social differences, most of the salmonella isolated were serotype B, C, or E. infections with these organisms appeared to occur as isolated outbreaks (Figure 1). Aetiology of diarrhoeal disease in Baghdad Results showed that food-borne infections due to Salmonella and Campylobacter are significant. Low numbers of Salmonella species may also be isolated from the faeces of healthy asymptomatic carriers, asymptomatic carriage of these organisms is common and they were also important causes of infantile diarrhea. Salmonella are mainly transmitted via dairy and meet products [32]. Poultry is believed to be an important reservoir for Campylobacter [33]. Infections with these organisms have been increasingly prevalent in recent years which coincide with increases poultry production in Baghdad. Rotavirus is the most common of the enteric pathogens isolated (29.5%), other similar studies [34] have reported that Rotavirus was detected in 28.5% of diarrhoeal children aged 5 years or under, other investigation in Basrah by Mahmood and Feachemt in 1987[35], Rotavirus was detected in 24% of cases. As previously reported the virus population is genetically diverse and varies with time [34]. In the present
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