Health and Medicine

A Multicentre Study of Shigella Diarrhoea in Six Asian Countries: Disease Burden, Clinical Manifestations, and Microbiology

Lorenz von Seidlein , Deok Ryun Kim, Mohammad Ali, Hyejon Lee, XuanYi Wang, Vu Dinh Thiem, Do Gia Canh, Wanpen Chaicumpa, Magdarina D Agtini, Anowar Hossain, Zulfiqar A Bhutta, Carl Mason, Ornthipa Sethabutr, Kaisar Talukder,G. B Nair, Jacqueline L Deen, Karen Kotloff, John Clemens
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Summary

Background The burden of shigellosis is greatest in resource-poor countries. Although this diarrheal disease has been thought to cause considerable morbidity and mortality in excess of 1,000,000 deaths globally per year, little recent data are available to guide intervention strategies in Asia. We conducted a prospective, population-based study in six Asian countries to gain a better understanding of the current disease burden, clinical manifestations, and microbiology of shigellosis in Asia. Methods and Findings Over 600,000 persons of all ages residing in Bangladesh, China, Pakistan, Indonesia, Vietnam, and Thailand were included in the surveillance. Shigella was isolated from 2,927 (5%) of 56,958 diarrhoea episodes detected between 2000 and 2004. The overall incidence of treated shigellosis was 2.1 episodes per 1,000 residents per year in all ages and 13.2/1,000/y in children under 60 months old. Shigellosis incidence increased after age 40 years. S. flexneri was the most frequently isolated Shigella species (1,976/2,927 [68%]) in all sites except in Thailand, where S. sonnei was most frequently detected (124/146 [85%]). S. flexneri serotypes were highly heterogeneous in their distribution from site to site, and even from year to year. PCR detected ipaH, the gene encoding invasion plasmid antigen H in 33% of a sample of culture-negative stool specimens. The majority of S. flexneri isolates in each site were resistant to amoxicillin and cotrimoxazole. Ciprofloxacin-resistant S. flexneri isolates were identified in China (18/305 [6%]), Pakistan (8/242 [3%]), and Vietnam (5/282 [2%]). Conclusions Shigella appears to be more ubiquitous in Asian impoverished populations than previously thought, and antibiotic-resistant strains of different species and serotypes have emerged. Focusing on prevention of shigellosis could exert an immediate benefit first by substantially reducing the overall diarrhoea burden in the region and second by preventing the spread of panresistant Shigella strains. The heterogeneous distribution of Shigella species and serotypes suggest that multivalent or cross-protective Shigella vaccines will be needed to prevent shigellosis in Asia.

Key Points

  • 1Shigellosis causes over a million deaths annually in resource-poor countries
  • 2High incidence rates of treated shigellosis were noted, especially in children under five
  • 3S. flexneri is the most commonly isolated species, with varying resistance profiles
  • 4There is a concerning rise in antibiotic-resistant Shigella strains across the studied regions
  • 5The study emphasizes the necessity for better prevention strategies and development of vaccines tailored to local strains.

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