Objectives. To describe the epidemiology, clinical features, management and outcome of children with Shigella dysenteriae type I infection admitted to a rural district hospital. Design. Prospective cohort study. Setting. Hlabisa Hospital, KwaZulu-Natal. Subjects. Children aged under 12 years admitted with a history of bloody mucoid diarrhoea between February and December 1995. Main outcome measures. Number of admissions, age, sex, clinical features, complications and outcome. Results. Between February and December 1995, 158 cases of bloody diarrhoea were admitted, compared with 6 the previous year. Shigella dysenteriae type I, resistant to ampicillin, tetracycline, chloramphenicol, trimethoprim and sulphamethoxazole, but susceptible to nalidixic acid and ceftriaxone, was isolated. The mean age of patients was 30 months. Patients typically presented with frequent bloody mucoid diarrhoea, fever, abdominal pain and dehydration. One hundred and sixteen (73%) recovered, 17 (11%) were transferred for tertiary care, 4 (3%) absconded, and 21 died (case fatality rate = 13%; 95% confidence interval (CI) 8 - 20). Seventeen (11%) developed haemolytic uraemic syndrome and 4 (3%) a protein-losing enteropathy. The malnourished (adjusted relative risk (RR) 3.3, 95% CI 1.6 - 7.1; P < 0.01) and those aged less than 2 years (adjusted RR 4.2; 95% CI 1.0 - 17.2; P = 0.05) were more likely to die. Dysentery deaths accounted for 19% of total paediatric hospital mortality. Conclusion. A serious epidemic of shigella dysentery has established itself and is having a significant impact in this area. The virulence and drug resistance of the organism has resulted in high levels of morbidity and mortality Broad public health measures will be needed to contain the epidemic. Further community-based surveillance is urgently needed, as is research to determine modes and risk factors for transmission.4 page(s

Chopra, M.

Stirling, S.

Wilkinson, D.

Chopra, Mickey

Wilkinson, David

Stirling, Susy

Macquarie University ResearchOnline

Epidemic shigella dysentery in children in northern KwaZulu-Natal

University of Queensland eSpace

REFERENCES
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2. MCH programme, Family Health Division. Clean delivery: A complimentary
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3. Wond Health Organisation. Neonatal tetanus in Africa. Wkly Epidemiol Rec 1987;
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4. Antio-OOOng OE, Young MU, Effiong GE. Neonatal tetanus: Prevalence before
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(1): 163-169.
6. Department of National Health and Population Development. Immunization
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7. Galazka A, Stroh G. Guidelines on the communify based survey on neonatal
tetanus mortallty_ &panded Programme on Immunisation. Geneva: WHO, 1986.
8. Patel JC, Joag GG. Grading of tetanus to evaluate prognosis. Indian J Med Sci
1957; 13: 834-840.
9 Department of National Health and Population Development. Tetanus
neonatorum. Epidemiological Comments 1990; 19(5): 8-17.
10. Department of National Health and Population Development, Tetanus
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11. Salimpour A. Causes of death in tetanus neonatorum. Arch Dis Child 1977; 52:
587-589.
12. Godel JC. Trial of pyridoltine therapy for tetanus neonatorum. J Infect Dis 1982:
145: 547-549.
Accepted 16 Jan 1995.
_ Volllme 87 No. 1 January 1997 SAMJ
Epidemic shigella
dysentery in children in
northern KwaZulu-Natal
Mickey Chopra, David Wilkinson, Susy Stirling
Objectives. To describe the epidemiology, clinicaJ features,
management and outcome of children with Shigella
dysenteriae type I infection admitted to a rural district
hospital.
Design. Prospective cohort study.
Setting. Hlabisa Hospital, Kwazulu-NataJ.
Subjects. Children aged under 12 years admitted with a
history of bloody mucoid diarrhoea between February and
December 1995.
Main outcome measures. Number of admissions, age,
sex, clinical features, complications and outcome.
Results. Between February and December 1995, 158
cases of bloody diarrhoea were admitted, compared with
6 the previous year. Shigella dysenteriae type I, resistant
to ampicillin, tetraCYCline, chloramphenicol, trimethoprim
and sulphamethoxazole, but susceptible to nalidixic acid
and ceftriaxone, was isolated. The mean age of patients
was 30 months. Patients typically presented with frequent
bloody mucoid diarrhoea, fever, abdominal pain and
dehydration. One hundred and sixteen (73%) recovered,
17 (11 %) were transferred for tertiary care, 4 (3%)
absconded. and 21 died (case fatality rate = 13%; 95%
confidence interval (Cl) 8 - 20). Seventeen (11 %)
developed haemolytic uraemic syndrome and 4 (3%) a
protein-losing enteropathy.
The malnourished (adjusted relative risk (RR) 3.3, 95%CI
1.6 - 7.1; P < 0.01) and those aged less than 2 years
(adjusted RR 4.2; 95%CI1.0 -17.2; P =0.05) were more
likely to die. Dysentery deaths accounted for 19% of total
paediatric hospital mortality.
Conclusion. A serious epidemic of shigella dysentery
has established itself and is having a significant impact in
this area. The virulence and drug resistance of the
organism has resulted in high levels of morbidity and
mortality. Broad public health measures will be needed to
contain the epidemic. Further community-based
surveillance is urgently needed, as is research to
determine modes and risk factors for transmission.
S Afr Med J 1997: 87: 48-51.
Centre for Epidemiological Research in Southern Africa, Medical
Research Council, and Hlabisa Hospital, Hlabisa, KwaZulu·Natal
Mickey Chopra. BSc, 8M, OCH
David Wilkinson. BSc, 1.18 ChB. O;p PEC. OCH, OTM&H, MSc (Epl)
Susy Stir1ing, MB ChB, OCH
Epidemic dysentery caused by multidrug~resistantShigella
dysenteriae type I, which is estimated to have killed up to
300 000 people in central and southern Africa in the last 4
years,' has now reached South Africa. King Edward VIII
Hospital, Durban, reported three times as many cases of
paediatric dysentery in the first 2 months of 1995 as in the
whole of most years prior to 1994.2 This species of shigella
has not previously been isolated in South Africa, but is
similar to the strain responsible for epidemics in Zaire and
Rwanda.2 Laboratory surveillance suggests that northern
Kwazulu~Natal is facing the initial brunt of this epidemic.3
The emergence of shigella dysentery is an important
public health threat. Shigella is extremely infectious,4 and
serotype 1 of S. dysenteriae is exceptionally virulent and is
associated with much higher rates of complications, such as
the haemolytic-uraemic syndrome (HUS), encephalopathy
and intestinal perforation. As in the present South African
situation, the organism is often resistant to most antibiotics
(e.g. ampicillin, co-trimoxazole, tetracycline and
chloramphenicol) commonly used in treatment.
Unfortunately conditions in many parts of South Africa are
still conducive to the rapid spread of this bacterium. It is
therefore important for medical officers, paediatricians and
public health officials to be fully aware of the epidemiology
and management of shigella dysentery.
The aim of this study was to describe the epidemiology,
clinical features, management and outcome of children with
S. dysenteriae type I admitted to a rural district hospital in
northern Kwalulu-NataJ.
Methods
Setting
Hlabisa health district is situated in northern Kwazulu-Natal,
and extends from the Umfolozi River in the south to the
town of Hluhluwe in the north. It incorporates both the
coastal region and the higher inland area and serves a
predominantly rural population of 205 000 people. The rainy
season is from October to March, but the area has suffered
a severe drought for the last few years. As in many rural
areas potable water is scarce, and most people draw water
from unprotected sources such as rivers. Latrines are not
commonly used.
Hlabisa Hospital is a 450-bed rural district hospital. The
3D-bed paediatric ward admits about 1 400 children a year,
and of these about 200 have diarrhoea as a primary
diagnosis. Prior to the current epidemic there were between
5 and 10 admissions for dysentery, with unidentified
aetiology, each year.
I
SAMJ
ARTICLES
Following isolation of S. dysenten'ae type I from the initial
cases, any child presenting with dysentery was presumed to
have shigella dysentery.
Analysis
Data capture and analysis were undertaken with Epi-Info
version 6.02 (Centers for Disease Control, Atlanta, USA).
Continuous data were compared by the non-parametric
Kruskal-Wallis test. Comparison of categorical data was by
the chi-square test. Exact confidence intervals are reported
and all P-values are two-tailed with values of le?s-than 0.05
considered statistically significant. The Mantel-Haenszel chi-
square test was used for stratified analysis. Associations
between variables are reported as relative risks (RRs).
Results
Between February and December 1995, 358 children with a
primary diagnosis of diarrhoea were admitted to Hlabisa
Hospital; 200 had non-bloody diarrhoea and 158 (44%) had
dysentery. By comparison, during the same period in 1994,
only 6 children had been admitted with dysentery, while the
number with non-bloody diarrhoea was around 200. S.
dysenteriae was isolated from the stool specimens of initial
patients in the Hlabisa Hospital laboratory, and was
confirmed at the Department of Medical Microbiology,
University of Natal, Durban, where the organism was typed
as S. dysenteriae type I. Isolates were resistant to ampicillin,
tetracycline, chloramphenicol, trimethoprim and
sulphamethoxazole, but were susceptible to nalidixic acid
and cettriaxone. The mean age of children with dysentery
(Fig. 1) was 30 months (range 3 - 144), and there were more
boys (91; 58%) than girls. Patients typically presented with
frequent bloody diarrhoea, fever, abdominal pain and
dehydration.
:IJ~ T
'30 1
,:1
Fig. 1. Age distribution of admissions and mortality.
Nutritional status
Forty-four (28%) children were underweight for age and 18
(11 %) were severely malnourished, i.e. had kwashiorkor,
marasmus or marasmic kwashiorkor.
SUbjects
All children under the age of 12 years admitted to the
paediatric ward and intensive care unit with a diagnosis of
dysentery between February and December 1995 were
included in the study. Dysentery was defined as a history of
passing loose, bloody mucoid stools. Children with
dysentery were admitted if they were pyrexial, grossly
dehydrated, had abdominal swelling or guarding, were
malnourished or had reduced levels of consciousness.
~
!o SUtvlved I
Age (Months)
SAMJ Volumt' 87 No. I Janu.ary 1997 __
Outcome
In all, 116 children (73%) recovered and were discharged
well, 17 (11 %) were transferred for tertiary care and 4 (3%)
absconded from the ward. Twenty-one children were known
to have died (case fatality rate 13%; 95% CIB - 20). Ten
children died within 2 days of admission.
When data were adjusted for age, severely malnourished
children were more likely to die than well-nourished children
(RR 3.3; 95% Cl 1.6 -7.1; P < 0.01). When nutritional status
was adjusted for, those aged less than 2 years were also
more likely to die (RR 4.2; 95% Cl 1.0 - 17.2; P = 0.05)
(Fig. 1).
Mortality from dysentery accounted for 19% of total
hospital paediatric mortality. The case fatality rate was
lower in the second half of the epidemic (July - December)
(RR =2.53; 95% Cl 1.0 - 7.2; P =0.05) (Fig. 2).
'"•§
z "
Fig. 2. Monthly admissions and deaths.
Complications
Seventeen children (11 %) developed HUS (defined as
haemolytic anaemia with anuria or oliguria) and 15 of these
were transferred for tertiary care. Four children (3%)
developed a protein-losing enteropathy, and 1 developed
signs of a perforated bowel but died before the diagnosis
could be established.
Discussion
We report the significant impact of the epidemic of S.
dysenteriae type I dysentery in KwaZulu-Natal on children
admitted to a rural hospital. There was a 26-fold increase in
the number of dysentery admissions during the study
period, and almost 1 in 5 children who died in hospital died
of dysentery.
This was a hospital-based study and did not consider
cases occurring in the community that did not reach health
facilities, or cases managed in clinics and the outpatient
department (of which there were many). It therefore only
provides an indication of the magnitude and severity of the
epidemic. Community-based studies are required to provide
a more comprehensive picture. Although amoebic dysentery
_ Volume 87 No. I January 1997 SAMJ
is endemic in this area, Entamoeba histalytica does not
cause large epidemics of dysentery with high fatality rates.
Investigations of dysentery epidemics in central Africa show
E. histolytica infections to be rare. 5.6 Furthermore, our
laboratory and those in neighbouring hospitals have
consistently grown S. dysenteriae type I from children with
dysentery during the current epidemic, and this was
confirmed at a reference laboratory. It is therefore
reasonable to assume that virtually all the 158 cases of
dysentery reported here were caused by S. dysenteriae
type I, although a microbiological diagnosis was not
obtained in all cases.
This epidemic has serious public health consequences.
The exceptional virulence and resistance of this organism
have made clinical management difficult. We have adopted
the following approach. All children undergo full blood
counts (including platelets), and urea and electrolyte and
creatinine estimation on admission. If severely dehydrated
they receive intravenous fluids (plasmalyte or Ringer's
lactate solution if hyponatraemic, half-strength Oarrow's
solution if serum sodium levels are normal), otherwise oral
intake is encouraged. Children with signs of systemic
toxicity are given parenteral ceftriaxone; those who are less
sick are given nalidixic acid. In most cases the dysentery
takes about a week to settle and children are discharged as
soon as they are eating and stool frequency has decreased.
Nearly 40% of our patients were either underweight for
age or severely malnourished. It is thought that malnutrition
may contribute to increased mortality by increasing
susceptibility to secondary infection. 7 Therefore
malnourished children should be more closely monitored for
secondary infections, especially those caused by Gram-
negative organisms. It should also be noted that the child
will be catabolic and attention must be paid to the provision
of nutritional support. Both severe malnutrition and young
age were independent risk factors for death.
The proportion that developed HUS is also noteworthy.
This dangerous complication was usually heralded by falling
urine output and development of anaemia. Almost half the
patients were admitted with normal biochemical and
haematological findings, and deteriorated a few days later.
This highlights the need for careful daily clinical and
laboratory review. We noted that mothers were very good
observers of falling urine output. If HUS is suspected, it is
important urgently to check renal function and blood count
and to discuss with a referral centre the need for possible
dialysis. Such children can deteriorate very quickly. We were
unable to follow these children up, and cannot report on
their outcome either in terms of mortality or renal function.
The case fatality rate of 13% is in keeping with
international experience.s Over the course of the epidemic,
the case fatality rate fell. The age distribution, complication
rate and proportion of malnourished children remained the
same and we believe the fall in mortality may be attributed
to our increased awareness of the complications and
management of this disease and the development of
treatment protecols. It is essential that a teaching
programme of the clinical manifestations and management
of shigella dysentery be instituted for clinic staff and medical
officers, along with the wide distribution of standardised
treatment protocels.
SAMJ
ARTICLES
Epidemiology of post-
neonatal bacterial
meningitis in Cape Town
children
Bacterial meningitis is a major cause of childhood
morbidity and mortality in South Africa. However,
comprehensive regional or national epidemiological data,
essential for rational public health interventions, are
lacking. The purpose of this 1-year prospective study, from
1 August 1991 to 31 July 1992, was to define the
magnitude of the problem of childhood bacterial
meningitis in Cape Town. The study group consisted of all
children. aged> 1 month to < 14 years, who. presented
with proven bacterial meningitis at all the hospitaJs in the
Cape Town metropolitan area. During the year 201 cases
were identified: 101 (50.2%) were due to Neisseria
meningitidis, 74 (36.8%) were due to Haemophilus
infJuenzae and 26 (12.9%) were due to Streptococcus
pneumoniae. The overall incidence rate (95% confidence
interval) for children less than 14 years. 5 years and 1 year
was 34 (30 - 40), 76 (65 - 88) and 257 (213 - 309) per
100 000 children, respectively. The rate was highest in
black infants, 416 (316 - 545)/100 000. This was 2 times
greater than the rate in coloured infants and about 4.5
times greater than the rate in white infants. The median
age of all the children was 10 months. The ages of
children with haemophilus and pneumococcal meningitis
were similar, 9 and 7.5 months respectively (P = 0.43),
while children with meningococcal meningitis were
significantly older (22 months) than the others (P < 0.01).
The overall case fatality rate was 5%, and 12.9% of
survivors had significant neurological sequelae (disability)
on discharge.
International experience suggests that this epidemic is not
going to be short-lived. At Hlabisa we are now redirecting
our energies towards increasing community awareness and
instituting preventive strategies. A clinical case definition of
a history of bloody mucoid diarrhoea has been adopted and
health workers are asked to notify all cases that they see. A
surveillance system has been established to determine the
distribution of disease in order to target interventions and to
evaluate their effectiveness. Research is needed to
determine modes of and risk factors for transmission.
The emergence of this epidemic has once again reminded
us of the many social, economic and health needs of our
communities. It is crucial that we take this opportunity to
galvanise all departments involved in delivering primary
health care and start the process of improving the water and
sanitation and health facilities in impoverished areas.
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Accepted 28 Qct 1996.
G Hussey, H Schaaf,
G Coelzee, J Pitout,
o Hanslo, J Hitchcock,
H Malan, P Donald
Departments of Paediatrics and Child Health and Medical
Microbiology. University of Cape Town .
G Hussey. MB ChB. MMed (Comm Healtnl. FfCH, DTM&H, MSc lOin Trap Med)
o Hansio. MB ChS. FFPalh (Mi=>biol}. MRC Pmi1
H Malan. S0Jrr~
Departments of Paediatrics and Child Health and Medical
Microbiology. University of Stellenbosch. Tygerberg, W. Cape
H Schaaf. MS ChS. DCM. MMed (Paed)
J Pitout MS ChB. FFPaIh. MMed (MicrobioI Path)
P Donald. MB O1S. DCH. MRCP. FCP. MD
South African Institute for Medical Research, Cape Town
J Hitchcock. Nat Dip Med Teen
G Coetzee. MS 018, MSc (Med~. MMed (Comm Health)
SAMJ Volume 87 No. 1 January 1997 _


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