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Malnutrition and enteric infections in children in Bengo province, Angola-a four-arm experimental study
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Introdução: À semelhança de outros países de baixo-médio rendimento, em Angola, a malnutrição e a doença diarreica estão entre as principais causas de mortes em crianças menores de cinco anos, nomeadamente na província do Bengo.
Objectivos: i) identificar a etiologia da diarreia e fatores associados em crianças menores de cinco anos atendidas no Hospital Geral do Bengo (HGB); ii) fornecer informações sobre a caracterização molecular de rotavírus, antes da introdução da vacina; iii) fornecer uma caracterização molecular de Giardia lamblia; e iv) investigar se o tratamento de parasitas intestinais (com ou sem diagnóstico prévio) em dois níveis diferentes (individual ou a nível do agregado familiar) tem impacto sobre o estado nutricional de crianças de 2-5 anos, após seguimento de dois anos no Bengo.
Métodos: Um estudo transversal (ET) foi implementado para investigar a presença de vírus, bactérias e parasitas nas fezes diarreicas de 344 crianças atendidas no HGB (2012- 2013), recolhendo dados sociodemográficos, nutricionais e clínicos, explorados por modelos de regressão logística simples e múltipla. Posteriormente, realizaram-se métodos moleculares para identificação dos genótipos circulantes de rotavírus e genótipos e subgenótipos de G. lamblia. Entre 2013 e 2017, um estudo longitudinal e experimental (RCT) com quatro braços em paralelo foi realizado em crianças infetadas com pelo menos
um parasita intestinal patogénico (ISRCTN-72928001). As 121 crianças com critérios de inclusão foram distribuídas aleatoriamente (1:1:1:1) - Braço1: albendazol anual a nível individual; Braço2: albendazol anual ao agregado familiar; Braço3: diagnóstico e tratamento quadrimestral de parasitas intestinais a nível individual; Braço4: diagnóstico
e tratamento quadrimestral de parasitas intestinais ao nível do agregado familiar. No início do estudo, aos 4, 8, 12, 16, 20 e 24 meses de acompanhamento avaliou-se: a altura, o peso, estatura-para-idade, peso-para-altura e peso-para-idade em Z-score. A análise por
intenção-de-tratar foi realizada seguindo as diretrizes CONSORT, após a análise de valores omissos (IBM SPSS). Dada a falha dos pressupostos da análise paramétrica de medidas repetidas, uma abordagem não paramétrica (nparLD) e os modelos LMM e GEE
foram explorados no programa R. Resultados: Nos dois estudos, as crianças viviam principalmente em áreas urbanas (>90%) e mais de 20% não tinha latrina. A água mais usada para beber provinha do rio,
da torneira no quintal e de tanques. A desnutrição crónica ocorreu em 38% (ET) e 31% (RCT) das crianças. No ET, 67% das crianças estavam infetadas por um agente enteropatogénico, principalmente por Cryptosporidium spp. (30%), rotavírus (25%) e G. lamblia (22%). Cryptosporidium spp. e rotavírus foram mais frequentes em menores de
12 meses. Os principais genótipos circulantes de rotavírus foram: G1P [8] (47%), G1P [6] (29%) e G2P [4] (13%). O genótipo B de G. lamblia foi predominante em relação ao genótipo A. No RCT, no início do estudo, as crianças estavam infetadas principalmente com G. lamblia (57%) e Ascaris lumbricoides (26%). Diferentes modelos não forneceram nenhuma evidência ou fraca evidência do efeito das intervenções nas medições antropométricas, embora tenha ocorrido uma evolução temporal significativa. Contudo, nota-se uma redução da desnutrição ligeira ao longo do estudo, apesar de, em média, as
crianças permaneceram com valores padronizados (z-scores) negativos para os índices antropométricos.Conclusão: Várias infeções entéricas foram identificados nos dois estudos. No RCT, nenhuma das estratégias de tratamento de parasitoses intestinais se destacou com efeito significativo nos indicadores antropométricos estudados. A duração do RCT e o tamanho da amostra podem não ter sido suficientes para observar diferenças significativas. Por outro lado, realça-se a importância de uma abordagem multifatorial integrada com vista
à melhoria do estado nutricional (e.g., WASH, educação, alimentação adequada e acesso a cuidados de saúde).
Background: Similar to other low- and middle-income countries, in Angola, malnutrition and diarrhoeal disease are among the major causes of deaths in children under-five, namely in Bengo province. Aims: i) identify the aetiology of diarrhoea and associated factors in under-five children attending the Bengo General Hospital (HGB); ii) provide information on the molecular characterization of rotavirus, before the vaccine introduction; iii) provide a molecular characterization of Giardia lamblia; and iv) investigate if treatment of intestinal parasites (with or without previous diagnosis) in two different levels (individual or household) impacts on nutritional status of children 2-5 years, after a two-year follow-up in Bengo. Methods: A cross-sectional study (CSS) was conducted to investigate the presence of virus, bacteria and parasites in diarrhoeal stools of 344 children attending HGB (2012-2013), collecting sociodemographic, nutritional and clinical data, analysed by simple and multiple logistic regression models. Then, molecular methods were performed for the identification of rotavirus circulating genotypes and G. lamblia assemblages and subassemblages. Between 2013 and 2017, a four-arm randomised controlled trial (RCT, registration ISRCTN-72928001) was conducted longitudinally in children infected with at least one pathogenic intestinal parasite. 121 children meeting inclusion criteria were randomly assigned (1:1:1:1) - Arm1: annual albendazole at individual level; Arm2: annual albendazole at household level; Arm3: four-monthly screening and treatment of intestinal parasites at individual level; Arm4: four-monthly screening and treatment of intestinal parasites at household level. Height, weight, height-for-age, weight-for-height, and weight-for-age Z-score were assessed at baseline, 4, 8, 12, 16, 20, and 24 months of follow-up. Intention-to-treat analysis was performed following CONSORT guidelines, after a missing value analysis (IBM SPSS). Given the failure of assumptions for parametric repeated measurements, nonparametric rank-based method (nparLD), LMM and GEE models were performed in R program. Results: In both studies, children lived mainly in urban areas (>90%) and more than 20% did not have a latrine. The most commonly drinking water sources were the river, the tap in the yard and tank. Near 38% (CSS) and 31% (RCT) of children were stunted. In the CSS, 67% of children were infected with an enteropathogen, mostly with Cryptosporidium spp. (30%), rotavirus (25%) and G. lamblia (22%). Cryptosporidium spp. and rotavirus were more frequent in children under 12 months. The main rotavirus circulating genotypes were: G1P[8] (47%), G1P[6] (29%) and G2P[4] (13%). G. lamblia assemblage B was predominant compared with assemblage A. In the RCT, at baseline, children were mainly infected with G. lamblia (57%) and Ascaris lumbricoides (26%). Different models provided no evidence or weak evidence of the effect of interventions on anthropometric measurements, although a significant temporal effect occurred. A reduction in mild malnutrition occurred throughout the study, although, on average, children remained with negative z-scores for anthropometric indices. Conclusion: Several enteric infections were identified in both studies. In the RCT, none of the treatment strategies targeting intestinal parasites stood out with significant effect on the anthropometric indices studied. The duration of the RCT and the sample size may not have been sufficient to observe significant differences. On the other hand, it highlights the importance of an integrated multifactorial approach to improving nutritional status (eg, WASH, education, adequate food and access to health care).
Background: Similar to other low- and middle-income countries, in Angola, malnutrition and diarrhoeal disease are among the major causes of deaths in children under-five, namely in Bengo province. Aims: i) identify the aetiology of diarrhoea and associated factors in under-five children attending the Bengo General Hospital (HGB); ii) provide information on the molecular characterization of rotavirus, before the vaccine introduction; iii) provide a molecular characterization of Giardia lamblia; and iv) investigate if treatment of intestinal parasites (with or without previous diagnosis) in two different levels (individual or household) impacts on nutritional status of children 2-5 years, after a two-year follow-up in Bengo. Methods: A cross-sectional study (CSS) was conducted to investigate the presence of virus, bacteria and parasites in diarrhoeal stools of 344 children attending HGB (2012-2013), collecting sociodemographic, nutritional and clinical data, analysed by simple and multiple logistic regression models. Then, molecular methods were performed for the identification of rotavirus circulating genotypes and G. lamblia assemblages and subassemblages. Between 2013 and 2017, a four-arm randomised controlled trial (RCT, registration ISRCTN-72928001) was conducted longitudinally in children infected with at least one pathogenic intestinal parasite. 121 children meeting inclusion criteria were randomly assigned (1:1:1:1) - Arm1: annual albendazole at individual level; Arm2: annual albendazole at household level; Arm3: four-monthly screening and treatment of intestinal parasites at individual level; Arm4: four-monthly screening and treatment of intestinal parasites at household level. Height, weight, height-for-age, weight-for-height, and weight-for-age Z-score were assessed at baseline, 4, 8, 12, 16, 20, and 24 months of follow-up. Intention-to-treat analysis was performed following CONSORT guidelines, after a missing value analysis (IBM SPSS). Given the failure of assumptions for parametric repeated measurements, nonparametric rank-based method (nparLD), LMM and GEE models were performed in R program. Results: In both studies, children lived mainly in urban areas (>90%) and more than 20% did not have a latrine. The most commonly drinking water sources were the river, the tap in the yard and tank. Near 38% (CSS) and 31% (RCT) of children were stunted. In the CSS, 67% of children were infected with an enteropathogen, mostly with Cryptosporidium spp. (30%), rotavirus (25%) and G. lamblia (22%). Cryptosporidium spp. and rotavirus were more frequent in children under 12 months. The main rotavirus circulating genotypes were: G1P[8] (47%), G1P[6] (29%) and G2P[4] (13%). G. lamblia assemblage B was predominant compared with assemblage A. In the RCT, at baseline, children were mainly infected with G. lamblia (57%) and Ascaris lumbricoides (26%). Different models provided no evidence or weak evidence of the effect of interventions on anthropometric measurements, although a significant temporal effect occurred. A reduction in mild malnutrition occurred throughout the study, although, on average, children remained with negative z-scores for anthropometric indices. Conclusion: Several enteric infections were identified in both studies. In the RCT, none of the treatment strategies targeting intestinal parasites stood out with significant effect on the anthropometric indices studied. The duration of the RCT and the sample size may not have been sufficient to observe significant differences. On the other hand, it highlights the importance of an integrated multifactorial approach to improving nutritional status (eg, WASH, education, adequate food and access to health care).
Descrição
Palavras-chave
Saúde pública Saúde internacional Desnutrição Diarreia Desparasitação Crescimento Longitudinal
Contexto Educativo
Citação
Editora
Instituto de Higiene e Medicina Tropical