Diarrheal correlates associated with enteric bacterial infections among children below five years in Murang'a County, Kenya

Introduction The burden of childhood diarrheal disease has resulted in massive mortality and morbidity globally. Children below 5 years in sub-Saharan Africa are most implicated by diarrheal illnesses resulting in numerous medical consultations, admissions, and deaths despite the disease being easy to prevent and control. The study aimed to determine the correlates of enteric bacterial infection causing diarrhea. Methods During the months of April-October 2017, 163 children below five years presenting with diarrhea were randomly selected in Murang'a and Muriranja's hospitals. Bacterial agents were identified and correlates of diarrhea determined. The study used a hospital-based cross-sectional study design. A standardized questionnaire was used to collect information from the guardian. Statistical analyses were performed using STATA v. 13. Results Forty-nine children were infected with enteric pathogenic bacteria (Enterotoxigenic Escherichia coli, Enteropathogenic Escherichia coli, Enteroaggregative Escherichia coli, Salmonella, Shigella, and Vibrio species). Factors associated with infection by these bacteria among the 49 children were evaluated. Children between 0-12 months (OR 0.3, 95% CI 0.1-0.8), those fed exclusively on breast milk (OR 0.3, 95% CI 0.09-0.9) and children weighing 1-5 kilograms (OR 0.2, 95% CI 0.04-0.9) were less likely to be infected with these enteric pathogenic bacteria. Female participants (OR 1.8, 95% CI 1.1-3.4) were nearly twice likely to be infected with enteric pathogenic bacteria. Children who presented with watery stool (OR 0.4, 95% CI 0.2-0.9) or mucoid stool (OR 0.3, 95% CI 0.2-0.7) remained associated with enteric pathogenic bacterial infection but less likely to be infected compared to those who presented with watery-blood stained stools. Piped water (OR 0.01, 95% CI 0.01-0.4) was less associated with enteric bacterial infection than water stored in jerry-cans while storing water without a lid (OR 1.9, 95% CI 1.1-3.7) was more likely to lead to bacterial infection. Hand washing after toilet use (OR 1.6, 95% CI 1.1-2.7) was associated with enteric bacterial infection compared to hand washing before meal preparation. Conclusion Sanitation, hygiene, nutritional and clinical factors were associated with enteric bacterial infections causing diarrhea among children below five years in the study area. Childhood diarrhea in Murang'a County is a major public health problem.


Introduction
Tremendous efforts, through global initiative, has seen diarrheal mortalities reduce substantially in the last two decades but diarrhea remains the top two killer disease, responsible for 72% deaths of children below two years [1], claims the lives of about 800,000 children below five years annually [2], and the leading cause of death among children of this age in Sub-Saharan Africa (SSA) [3]. Fischer Walker et al. [1] in the year 2011 observed Kenya as among the ten countries in SSA where childhood mortality associated with diarrhea disease burden is alarming. Sixteen percent (16%) of deaths in Kenya have been associated with diarrhea among children who do not live to see their 5th birthday [4]. The burden of diarrhea in Kenya remains elusive with unacceptable morbidity and mortalities among children below five years. Deficiencies in preventive, diagnostic and treatment infrastructures are still major stabling blocks both at local and community levels [5]. Preventable diseases account for 80% medical consultations in Kenya while half of these are sanitation and hygienerelated such as diarrhea which is ranked as top three illness among children below 5 years [6].
Transmission of enteric bacteria-causing diarrhea is mainly through the fecal-oral route. Simple interventions that have proven feasible in the prevention of diarrheal illnesses [7,8], but certain enteric bacteria continue to proliferate in nearly all environments and causes diarrhea among children below 5 years. Hygiene, sanitation, nutrition, and socioeconomic factors are key and a priority against transmission and infection of enteric bacterial pathogens causing gastroenteritis [9].
Cheap, efficient and sustainable interventions such as water treatment [10], hand washing with soap and water [11], and balanced diet have been demonstrated to effectively minimize diarrheal disease.
Educating the community on the importance of behavioral changes through health promotion programs offers a long-term solution in the fight against enteric diarrheal illnesses among children below five years. The study identified factors associated with enteric bacterial infection among children below 5 years calling the need for immediate action for implementation of public health interventions.

Methods
Study site: the study was carried out in Murang'a County, Kenya, located about 80 kilometers from the Kenyan capital, Nairobi. Two major referral hospitals within the county were selected (Murang'a referral hospital and Muriranja's tier 4 hospital).
Research design: a hospital-based cross-sectional study approach was used. Sample size determination: applying the formula for estimating the population proportion with specified relative precision described by Daniel [12] setting the α at 0.05, and a detection rate of 12.1% for children below five years infected with diarrheal disease in Murang'a County [13], a total of 163 children were recruited to achieve 0.95 power. were less to be infected with enteric pathogenic bacteria compared to children aged between 49 to 60 months.

Data collection instruments
Feeding and gastrointestinal factors: among the feeding and gastrointestinal associated factors, in the bivariate analysis, breastfeeding was found associated with enteric pathogenic bacterial infection. Children who were fed exclusively on breast milk (OR 0.3, 95% CI 0.09-0.9) were less likely to be infected with these enteric pathogenic bacteria compared to those who were currently not breastfeeding ( Table 2). Hygiene and sanitation factors:  [16] in Kenya who reported that female between 6-36 months were twice likely to be infected by enterobacteriaceae than their male counterparts. In rural Sudan, an earlier study reported that female children less than 5 years were more at risk of diarrhea [18]. Our data output showed an association between gender with enteric pathogenic bacterial infection and female accounted for more than a double fold-frequency of isolated bacteria.

Child's clinical presentations:
Even though one gender may slightly be inflicted by bacterial pathogens, significance may not be strong enough to show a positive or negative association. For instance, even though male (54%) were more inflicted by diarrhea in a Nigerian teaching hospital, sex was not significantly related to the odds of having diarrhea [19]. Some authors, however, indicate an equal probability of diarrhea frequency between gender [20] while other studies in Kenya [21], Sudan [22], Tanzania [23] and India [24] contradict our finding indicating the male gender were more likely to be inflicted by enterobacteriaceae.
Association between gender with enteric pathogenic bacterial infection among children less than 5 years is an area that requires further exploration due to various variables such as immunological factors, demographic features and environmental factors across the globe.
Weight and Nutrition: from our finding, the less heavy infants between 1-5 kilograms appeared to be protected (OR 0.2, 95% CI 0.04-0.9) against enteric pathogenic bacteria compared to heavier children who weighed 16 to 20 kilograms. It is possible that these infants were below 6 months and the majority were exclusively being breast-fed. Breastfeeding exclusively for 6 months or more appeared to have significantly reduced the risk of one or more episodes of Gastro-Intestinal Tract (GIT) infection [25] and less than 10 folds risk of death [26]. Diarrhea and malnutrition have a bi-directional relationship whereby the course of diarrhea worsens due to malnutrition [27]. Malnutrition alters vital metabolic processes such as reduced bile-acid synthesis, digestive enzymes, motility and shift of gut flora elevating probability of enteric infections causing diarrhea.
Vibrio cholera infection leads to loss of 1 litre of water per hour resulting in severe hypotensive shock and high case fatality rates [28].
Repeated frequencies of enteric infections and diarrhea results in poor nutrient absorption. Specifically, from our study, nutrition status was not associated with enteric pathogenic bacterial infection and this finding runs consistently with an observation from an earlier study in Bangladesh that failed to demonstrate this relationship among preschool children [29]. Our finding, however, is at odds with a study that demonstrated the existence of a relation between malnutrition and diarrhea [30]. An explanation of our finding may be based on the nutritional supplements that were prescribed in the Maternal and Child Health (MCH) booklet. It is likely that the majority of the children who were attending postnatal clinics and had nutrition problems were on supplements to correct malnutrition and hence were less associated with diarrhea.
Breastfeeding: breastfeeding was found associated with enteric pathogenic bacterial infection. Those fed exclusively on breast milk (OR 0.3, 95% CI 0.09-0.9) were less likely to be infected with these enteric pathogenic bacteria compared to those who were currently not breastfeeding. Passive immunity from transplacental and breast milk antibodies protects the infant within the first six weeks [1]. Children who failed to breastfeed exclusively (first 6 months) were more than 3 folds at risk of contracting diarrhea in Imenti, Meru [31]

Competing interests
The author declares no competing interests.

Authors' contributions
Oliver Waithaka Mbuthia was the lead researcher of the entire research, involved in the draft submission and given approval for its publication.

Acknowledgments
Special thanks to all the study participants that were involved in this study. I recognize and appreciate all efforts from staff attached to Murang'a hospital, Muriranja's hospital, and Kenya Medical Research Institute. Table 1: socio-demographic factors associated with enteric pathogenic bacterial infection