Role of Infant Feeding and HIV in a Severe Outbreak of Diarrhea and Malnutrition among Young Children, Botswana, 2006
Tracy Creek*1, W Arvelo1, A Kim1, L Lu1, A Bowen1, T Finkbeiner1, L Zaks1, J Masunge2, N Shaffer1, and M Davis1
1CDC, Atlanta, GA, US and 2Botswana Ministry of Hlth
Background: In early 2006, a severe outbreak of diarrhea occurred among
young children, coinciding with heavy rains and widespread water contamination.
Pediatric diarrhea surveillance reported 3.5 times the usual number of cases
and 25 times the usual number of deaths between January and March. Cryptosporidium and enteropathogenic
E. coli were the most common
pathogens identified. Botswana
is HIV prevalent among pregnant women (33.4% in 2005 surveillance), and the
national program for prevention of mother-to-child transmission of HIV (PMTCT)
provides free infant formula and advises HIV-infected women not to breastfeed.
Many HIV– women also bottle-feed their infants. An estimated 35% of
all infants under the age of 6 months are not breastfed.
Methods: All pediatric inpatients <5 years old with diarrhea in
the country’s second-largest referral hospital from February 20 to March 10,
2006 were followed by chart review until April 10. Their mothers were
interviewed, and mothers and infants were tested for HIV.
Results: Of 154 diarrhea inpatients, 96% were <2
years old, 90% of those were not breastfed in the 2 weeks before illness, and
33 (21%) died. Among patients with HIV results, 23 of 131 (18%) were HIV
infected and 93 of 144 (65%) had an HIV+ mother. Malnutrition was
common: of 99 children, 51 (52%) with
growth records exhibited no growth in the previous 3 months; severe acute
malnutrition (kwashiorkor or marasmus) developed in
38 of 147 (26%) during or after the diarrhea. Kwashiorkor was a significant risk
factor for death (RR = 2.0, 95%CI 1.1 to 3.8) and tended to be more common in
HIV– children (27% vs 9%, RR 3.0, 95%CI
0.75 to 12.5). No breastfeeding children died (RR 6.1, 95%CI 0.39 to 93.4). HIV
in mother or child was not a risk factor for death. Infants who died while
receiving formula through the PMTCT program had received an average of 51% of
the formula they should have received after birth, and 60% had not gained
weight in the 3 months prior to illness.
Conclusions: Most of the severe morbidity and mortality
occurred in children who were HIV–, not breastfeeding, and not
growing well. Severe acute malnutrition following diarrhea was the most
important predictor of death, and was associated with inadequate prior formula
supply in some babies. Breastfeeding provides optimal nutrition and prevents
diarrhea, and policy revisions to increase breastfeeding among HIV–
and HIV+ women should be considered.