Aetiology of Children Diarrhoea in

Tripoli, Libya

Khalifa Sifaw Ghenghesh1,

Salaheddin Shaban Abeid1,
Fauzi Bara2, and
Belqis Bukris2.

Dept. of Medical Microbiology1, Faculty of Medicine and

Aljala Children Hospital2,
Tripoli - Libya

Correspondence:
Dr. Khalifa Sifaw Ghenghesh, MSc, PhD, DipBact
Dept. of Medical Microbiology,
Faculty of Medicine,
P.O. Box 80013
Tripoli - Libya
Fax: +218 21 333 4474
Tel: +218 21 444 7343

To cite this paper:

Ghenghesh KS., Abeid SS., Bara F., and Bukris B. 2001. Aetiology of Childhood
Diarrhea in Tripoli-Libya. Jamahiriya Med J; 1 (2): 23-29.
SUMARRY:
During a one year period stool samples from 157 children (72 females) with

diarrhoea (cases) and 157 age-and sex-matched controls were examin-ed for

enteropathogens. The age of the children ranged from a few days to 3 years.

Enteropathogens were detected in 61.1% of cases and 31.2% controls, single pathogen

in 41.4% and 25.5%, rotavirus in 31.9% and 2.2%, Salmonella in 10.8% and 3.8%,

Shigella in 5.7% and 1.3%, Yersinia entero-colitica in 0.6% and 0.0%,

enteropathogenic Escherichia coli (EPEC) in 11.4% and 7.0%, E. coli O157 in 7.0%

and 4.4%, Aeromonas in 14.6% and 17.8% and Campylobacter in 6.3% and 3.1%

respectively. Of these entero-pathogens only Shigella spp. were isolated significantly

more from chidren >12 months and EPEC serogroups were isolated significantly

more from children <6 months. Nearly 40% of cases were with fever and vomiting,

about 11% were dehydrated and more than 3% were with generalized convulsions.

Presence of frank blood and mucus in the stool was observed in more than 8% and

39% respectively. Less than nine per cent (8.9%) of cases were given oral rehydration

salts (ORS) before stool collection. A statistically significant association was

observed between the cases and artificial feeding and between controls and breast

feeding. The findings of this study confirms the role of rotavirus, Salmonella and

Shigella in children diarrhoea in Tripoli area. It also demonstrates the need for a

vigorous educational programme that promotes the benefits of using ORS and breast

feeding.
INTRODUCTION:
Diarrhoea in children is a major health problem. It is the leading cause of

illness and death and an important cause of malnutrition among children in

developing countries (1,2). Diarrhoeal disease also represents an economic burden for

these countries. A number of classical agents are known as causes of diarrhoea in

children. These include rotavirus, Salmonella spp., Shigella spp., enteropathogenic

Escherichia coli, and enterotoxigenic E. coli. Recently, newer agents were added to

the list and include Aeromonas spp., Yersinia enterocolitica and E. coli O157:H7.

Although very few studies were carried out in Libya on the causes of diarrhoeal

disease in children, these studies suffered from a number of drawbacks that include

the search for a single agent only in the population studied, lack of controls and

detailed clinical data (3,4). Therefore, the main objective of this study was to

determine the viral and bacterial agents (including the newly emerging agents) of

diarrhoea and the related clinical features in children with acute diarrhoea and in age-

and sex-matched controls.

MATERIALS AND METHODS:
1. Study population:
Included in the study 157 children with diarrhoea (cases) attending the out-

patients clinic in Aljala Children Hospital in the city of Tripoli ( population ~1.250

000) and 157 age- and sex-matched controls. The controls were age-matched within

six months of age. The age of the children ranged from a few days to 3 years. Most

(86%) of children were less than one year of age. The study was carried out between

September, 1992 and August, 1993. Acute diarrhoea was defined as diarrhoea that

started <14 days before stool collection. Controls were those children who had no

diarrhoea or other gastrointestinal symptoms and had not received antibiotics during

the previous 30 days of stool sampling. Diarrhoea was defined as >3 liquid or semi-

liquid stools per day. Stool sample from each control was collected within 5 days

from that of the corresponding case.

Paediatricians of the investigation staff (FB, BB) collected the faecal samples,

noted the consistency and the presence of frank blood or mucus or both, performed

the clinical examination of the patients and controls and obtained the medical history

from the child's parents.

2. Microbiological methods:
To isolate salmonellae, shigellae, yersiniae, enteropathogenic Escherichia coli

(EPEC), E. coli O157:H7, Plesiomonas shigelloides, aeromonads and campylobacters,

stool specimens were cultured directly on the following media: Salmonella-Shigella

Agar (SSA), Yersinia-Selective Medium (YSM), MacConkey Agar, Sorbitol

MacConkey Agar for E. coli O157:H7, Blood Agar (BA), Blood Agar supplemented

with 15mg/L ampicillin (ABA), and Skirrow-Selective Medium (SKM). Specimens

were also inoculated into alkaline peptone water, pH 8.6 (APW), tetrathionate broth

(Tb) and phosphate buffer saline (PBS). With the exception of PBS and the YSM all

media were incubated overnight at 37oC. A loopful from APW was inoculated onto

ABA and a loopful from Tb onto brilliant green agar and both media were incubated
for 18-24 hours at 37oC. PBS was incubated at 4oC and loopfuls were taken after 1, 2

and 3 weeks and inoculated onto YSM. The YSM plates were always incubated at

30oC for 48 hours. Suspected colonies from all the media were identified using

standard microbiological procedures (5,6) and the API 20E System (bioMerieux,

France) were appropriate. Strains identified biochemically as Salmonella and Shigella

were serotyped by antisera to O- and H-antigens of Salmonella and Shigella spp.

(Wellcome Diagnostics, UK)

Five-lactose positive and up to 5-lactose negative colonies from each faecal

specimen identified as E. coli were serogrouped using antisera (Eurobio, France) to

the O-antigens of EPEC as recommended by the manufacturer. Sorbitol non-

fermenting strains of E. coli were submitted for agglutination with O157:H7

antiserum (Unipath, UK). Rotavirus was identified with a monoclonal latex

agglutination test (bioMerieux, France). Rotavirus and campylobacters were studied

in 147 and 95 cases and in 90 and 95 controls respectively.

RESULTS:
Prevalence of enteropathogens: During a one year period, enteropathogens were

detected in 95 (61.1%) children with diarrhoea (cases) and in 49 (31.2%) controls (P<

0.05). A single pathogen was identified in 65 (41.4%) cases and in 40 (25.4%)

controls (P< 0.05) with rotavirus, Salmonella, and Shigella being found more

frequently in cases than in controls with a statistically significant difference. The

different enteric pathogens isolated from cases and controls are shown in Table 1.

Of the salmonellae detected in the present study only serotype Salmonella

saintpaul was significantly isolated from cases than from controls (Table 2). The

Shigella species were isolated from 9 (5.7%) case and from 2 (1.3%) controls. Of the

11 isolates 6 (54.5%) were Sh. flexneri (all from cases) and 5 were Sh. sonnei (3 from

cases).

Infection with serogroups representing enteropathogenic E. coli were detected

in 18 (11.4%) cases and 11 (7.0%) controls with the predominance of serogroups

O119 and O126 (Table 3). E. coli O157 was found in 11 (7%) and 7 (4.4%) cases and

controls respectively.

Aeromonas species were found in 23 (14.6%) diarrhoeic children and 28

(17.8) controls. Identification of the Aeromonas strains to the species level revealed

the isolation of A. hydrophila from 5 (3.2%) cases and 9 (6.4%) controls, A. sobria

from 8 (5.1%) and 7 (4.5%), A. caviae from 13 (8.3%) and 17 (10.8) and A. schubertii

from (0.6%) and 2 (1.3%) respectively. Multiple Aeromonas species were isolated

from 4 (2.5%) cases and 6 (3.8%) controls.

Age and sex distribution: Although rotavirus and Salmonella spp. were isolated at

higher rates from cases <12 months than from cases >12 months the differences were

not statistically significant. Shigella spp. were isolated significantly more from

chidren >12 months (P< 0.05). On the other hand, enteropathogenic E. coli

serogroups were isolated significantly more from children <6 months than from older

children (P< 0.05). In diarrhoeic children, only salmonellae infection was found
significantly higher in males [14 of 85 (16.5%)] than in females [3 of 72 (4.2%)]

(P<0.05).

Seasonal distribution: The differences in the isolation rates of the different

enteropathogens during the four seasons were not statistically significant, although

rotavirus, Salmonella, Shigella, Aeromonas and E. coli O157:H7 were isolated more

frequently during autumn and enteropathogenic E. coli was isolated more frequently

during summer.

Clinical features: Nearly 40% of the 157 (72 females) children with diarrhoea (cases)

included in the present study were with fever and vomiting, about 11% were

dehydrated and more than 3% were with generalized convulsions. In these cases,

presence of frank blood and mucus in the stool was observed in more than 8% and

39% respectively. The clinical features and stool characteristics of the children with

diarrhoea according to age are shown in Table 4.

Table 5 shows the positive predictive values of blood and mucus in stool and

of some clinical features for rotavirus, bacteria and combined infections, and

unknown aetiology. Seizures and presence of blood in the stool had predicitive values

of > 60 for bacterial infections. Other clinical features were not helpful in predicting

the aetiology of diarrhoea.

Asking the parents of the children with diarrhoea what type of medication or

treatment was given to their child at home showed that 53(33.7%) were given

antibiotics (mainly ampicillin or related antibiotics), 25(15.9%) a combination of

homatropinemethylbromide and phenobarbitone (for the treatment of gastrointestinal

spasms), 36(22.9%) paracetamol and 14(8.9%) were given oral rehydration salts

(ORS).

Parents of children less than 12 months were also asked about the type of

feeding of their children visa-viz breast, artificial or mixed (breast plus artificial

feeding). The results obtained showed a statistically significant association of breast

feeding with children without diarrhoea and artificial feeding with diarrhoeic children

(Table 6).
DISCUSSION:
The aetiology of childhood diarrhoea in industrialized and developing

countries have been reported by several investigators over the years (7,8,9,10,11).

Nearly all these studies agree on the importance of rotavirus as a major cause of

diarrhoea in children. Our results confirm the findings of these studies and show that

rotavirus is the leading causative agent of diarrheoa in Libyan children. It has been

reported that rotavirus-associated diarrhoea occurs at higher rates in winter in

temperate regions, in the rainy season and in the tropics and subtropics (8,12).

Although, in the present study, rotavirus as well as other infections (i.e. Salmonella,

Shigella, Aeromonas and EHEC) occured at a slightly higher rate in autumn, we

found no significant seasonal variations in the isolation rates of these agents. The

reason for this may be due to the mild winter in our region. However, similar findings

have been reported by others (12).

Of the bacterial agents associated with diarrhoea only Salmonella spp. and

Shigella spp. were isolated significantly more from cases than from controls. A study

on Salmonella isolations from human faecal samples obtained between 1975-1980

from cases of diarrhoea in hospitals and clinics in Tripoli identified 34 different

Salmonella serotypes, by far the most common being S. wein and S. muenchen (4). In

our study only 8 serotypes were detected with the predominance of S. saintpaul.

Furthermore, S. hadar was not among the 34 serotypes identified in the above

mentioned study. These differences could be due to differences in the age of the

populations studied and in the duration of the both studies. However, we have no

explaination to the isolation of Sallmonella from males at a rate significantly higher

than that of females.

Only Sh. sonnei and Sh. flexneri were isolated in the present work with the

later predominating. Similar findings were reported from Algeria and other Arab

countries (13, 14, 15). An outbreak of shigellosis occured recently in a Libyan family

of 8 members, we isolated Sh. flexneri from 5 members and from the contaminated

water used for drinking by all members of this family (16). The isolation of Y.
enterocolitica from one case only indicates that this organism may have no role in

children dirrhoea in Tripoli area.

Contrary to developing countries diarrhoeagenic E. coli are not an important

causes of diarrhoea in industralized countries (17,18). In a recent study from Italy E.

coli O157:H7 was not deteced and EPEC serogroups were isolated from a small

number (1.3%) of stool samples from children with diarrhoea (7). The isolation of E.

coli O157:H7 and EPEC serogroups from 7% and 11.4 of cases respectively confirms

the importance of these organisms in the causation of children diarrhoea in our region.

Furthermore, the predominance of EPEC serogroups O119 and O126 is in contrast to

reports from other developing countries were other serogroups (e.g. O111) dominates

(19).

The findings of the present study of EPEC serogroups in diarrhoeic children <

6 months and Shigella spp. in children > 12 months are similar to reports from other

developing countires (19, 20).

Aeromonas spp. are being increasingly recognized as agents of children

diarrhoea (21,22). As in other studies (7) we isolated Aeromonas spp. more frequently

from controls than from cases. This could be due to the presence of these organisms in

sources of water used for drinking in Tripoli area (23). The finding that A. caviae as

the predominant species in Libyan children with and without diarrhoea is in line with

other reports (21,24).

It is widely accepted that ORS is the corner stone in the treatment of mild

childhood diarrhoea. Furthermore, the World Health Organization is promoting the

use of ORS in all cases of severe diarrhoea including that due to Vibrio cholerae (25).

Studies have also shown that antibiotics are not indicated in uncomplicated, non-

typhoid salmonellosis and may prolong the excretion of salmonellae (26). The low

rate (< 9%) of Libyan parents using ORS and their high rate (>30%) of using

antibiotics in the treatment of diarrhoeic children demonstrates the seriousness of the

problem of diarrhoeal disease in our area. Furthermore, the problem is aggrevated still

more by the use of artificial feeding by mothers of diarrhoeic children aged less than
one year as shown by our findings (Table 6).

As it has been reported previously (7) the presence of blood in stools of

children with diarrhoea had a high positive predictive value for bacterial infections.

With the exception of seizures, clinical presentation was not sufficiently

characterisitic to assist in the presumptive diagnosis of a specific pathogen. These

findings confirm those reported by others (7).

In conclusion, this study is the first of its kind to be carried out in Libya. It

confirms the role of the well known agents (rotavirus, Salmonella, Shigella) in

children diarrhoea in Tripoli area. The isolation of E. coli O157:H7 and Aeromonas

spp. has not been reported previously in children in Libya and will serve as a basis for

comparison with future studies in this country and elsewhere. The misuse of

antibiotics and the lack of using ORS in the treatment of children diarrhoea in the

population studied demonstrates the need for a vigorous educational programme that

promotes the benefits of using ORS and breast feeding. More studies are needed to

determine the role of other enteric agents (e.g. enterotoxigenic E. coli, Giardia

lamblia, etc.) in childhood diarrhoea. Furthermore, studies are also needed to

determine the virulence factors of new enteric agents (e.g. Aeromonas spp. and E. coli

O157:H7) to clarify their role in diarrhoeal disease in developing countries.

ACKNOWLEDGEMENT:
Dr. K.S. Ghenghesh would like to thank Dr. F. El-Sager for his encouragment in

putting this work in writing.

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relative importance of Shigella in the aetiology of gastroenteritis in Saudi Arabia.

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clinico - epidemiologic prospective study and susceptibility to antibiotics. J Trop

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16. Ghenghesh KS., Abeid SS., Zelitini M. A family outbreak of bacillary dysentry

due to untreated sewage from a hospital. J. Hosp. Infec. 1998; 40 (Suppl. A): Abstract

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Table 1. Prevalence of potential enteropathogens in stools of 157
children with diarrhoea (cases) and in 157 controls
-----------------------------------------------------------------------------------------------------
No. (%) of isolates in
Enteropathogen Cases Controls P value
-----------------------------------------------------------------------------------------------------
Single 65 (41.4) 40 (25.5) 0.004
Multiple 30 (19.1) 9 (5.7) 0.0003
any pathogen 95 (61.1) 49 (31.2) 0.0000003
Rotavirus* 47 (31.9) 2 (2.2) 0.0000000
Salmonella 17 (10.8) 6 (3.8) 0.017
Shigella 9 (5.7) 2 (1.3) 0.03
Yersinia enterocolitica 1 (0.6) 0.0 (0) NS**
Enteropathogenic E. coli 18 (11.4) 11 (7.0) NS
E. coli O157 11 (7.0) 7 (4.4) NS
Aeromonas 23 (14.6) 28 (17.8) NS
Campylobacter* 6 (6.3) 3 (3.1) NS
-----------------------------------------------------------------------------------------------------
*Rotavirus and Campylobacter were studied in 147 and 95 cases and
in 90 and 95 controls respectively.
** Not significant.
Table 2. Serotypes of Salmonella isolated from 157 children
with diarrhoea (cases) and from 157 controls.
_______________________________________________
No. of each serotype isolated from
Serotype Cases Controls Total
-------------------------------------------------------------------------------------
S. saintpaul 7 1 8
S. wein 3 1 4
S. newport 2 - 2
S. muenchen 1 1 2
S. hadar 1 1 2
S. reading 1 1 2
S. typhimurium 1 1 2
S. kottbus 1 - 1
-------------------------------------------------------------------------------------
Total 17 6 23
_______________________________________________
Table 3. Serogroups of enteropathogenic E. coli isolated
from children with diarrhoea (cases) and from controls
in Tripoli-Libya.
------------------------------------------------------------------------------
No. (%) of isolates in
Serogroup Cases Controls
(n=157) (n=157)
------------------------------------------------------------------------------
O1 1 (0.6) 1 (0.6)
O18 1 (0.6) -
O44 - 1 (0.6)
O55 2 (1.3) -
O114 2 (1.3) -
O119 5 (3.2) 1 (0.6)
O125 1 (0.6) 1 (0.6)
O126 4 (2.5) 2 (1.3)
O127a - 1 (0.6)
O128 2 (1.3) 1 (0.6)
O146 1 (0.6) 2 (1.3)
O166 - 1 (0.6)
------------------------------------------------------------------------------
Total 19 (12.1)* 11 (7.0)
------------------------------------------------------------------------------
*Two different serogroups were isolated from one case.
Table 4. Clinical features and stool characteristics of children with
diarrhoea according to age.
________________________________________________________
Feature/ < 6 months 6-11 months > 1 year Total
Character (n=83) (n=50) (n=24) (n=157)
-----------------------------------------------------------------------------------------------------
Fever 28(33.7) 22(44) 12(50) 62(39.5)
Vomiting 32(38.6) 20(40) 11(45.8) 63(40.1)
Dehydration 10(12) 7(14) 0.0 17(10.8)
Seizures 2(2.4) 1(2.0) 2(8.3) 5(3.1)

Stool with:
frank blood 5(6.0) 4(8.0) 4(16.6) 13(8.2)
mucus 31(37.3) 15(30) 12(50) 58(36.9)
_________________________________________________________
Table 5. Predictive values positive of some stool and clinical features for rotavirus,
bacterial and combined infections, and for unknown aetiology.
_____________________________________________________________
Predictive Values (%) Positive for*
Feature ---------------------------------------------------------------------------
Rotavirus Bacterial** Combined rotavirus Unknown
infection infection & bacterial infection aetiology
_____________________________________________________________
Blood (n=13) 0.0 61.5 7.7 30.8

Mucus (n=58) 17.2 41.4 8.6 32.8

Fever (n=62) 22.6 32.3 9.7 35.5
Vomiting (n=63) 25.4 23.8 12.7 38.1
Dehydration (n=17) 11.8 29.4 23.5 35.3
Seizures (n=5) 20.0 60.0 20.0 0.0
_____________________________________________________________
* Number of cases with the feature and a given type of infection divided by total
number of cases with the feature.
**Includes infection with Salmonella, Shigella, Campylobacter, Yersinia
enterocolitica, enteropathogenic E. coli, E. coli O157 and Aeromonas .
Table 6. Type of feeding of 131 children with dirrhoea
aged < 12 months and 131 age- and sex- matched controls.
___________________________________________________
Children with
Type of feeding diarrhoea without diarrhoea P value
___________________________________________________
Breast 17(12.5) 32(24.4) 0.017
Mixed* 24(18.3) 31(23.7) NS**
Artificial 90(68.7) 68(51.9) 0.005
___________________________________________________
*Breast plus artificial feeding. **NS=not significant
Aetiology of Childhood Diarrhoea in Tripoli - Libya
Khalifa Sifaw Ghenghesh1*, Fauzi Bara2, Belqis Bukris2, and Salaheddin S. Abeid1
Dept. of Medical Microbiology1, Faculty of Medicine and Aljala Children Hospital2,
Tripoli - Libya

Diarrhoea in children is a major health problem. It is a cause of high mortality

and morbidity in developing countries. The present study was carried out to determine
the aetiology of diarrhoea in Libyan children in Tripoli area. Included in the study 157
children with diarrhoea (cases) and 157 age- and sex-matched controls. The age of the
children ranged from a few days to 3 years. Most (86%) of the children were less than
one year of age. The study was carried out between September, 1992 and August, 1993.
Standard methods were used to detect enteropathogens ( bacterial agents and rotavirus)
in the stool specimens. Rotavirus and Campylobacter spp were studied in 147 and 95
cases and in 90 and 95 controls respectively. Parasitic agents were not looked for in the
present study.
Rotavirus was detected in 35% of cases and 2% of controls, Salmonella spp. in
11% and 4%, Shigella spp. in 6% and 1%, Aeromonas spp. in 15% and 18%,
Campylobacter spp. in 6% and 3%, Yersinia enterocolitica in 0.6% and 0.0%,
enteropathogenic E. coli in 14% and 8%, and enterohaemorrhagic E. coli (serogroup
O157:H7) in 7% and 4% respectively. The results obtained shows that rotavirus is the
leading causative agent of gastroenteritis in the population studied. Also Salmonella and
Shigella spp. were isolated significantly more from diarrhoeal cases than from controls
(P< 0.05, Chi-square test).

Table . Signs and symptoms among children with diarrhoea, by pathogen identified in
stool.
_____________________________________________________________
% of Cases with
Pathogen Identified*---------------------------------------------------------------------------
Fever Vomiting dehydration Blood Mucus
_____________________________________________________________
Rotavirus (n=31) 45.2 48.4 6.5 0 35.5
Salmonella (n=8) 25 25 12.5 12.5 37.5
Shigella (n=6) 66.7 16.7 0.0 16.7 66.7
Aeromonas (n=11) 36.4 27.3 18.2 0.0 27.3
EPEC (n=3) 66.7 66.7 33.3 0.0 33.3
EHEC (n=4) 25 0.0 0.0 0.0 25
Campylobacter (n=3) 66.7 33.3 0.0 0.0 66.7
No pathogen (n=62) 36.5 38.1 9.5 6.3 28.6
_____________________________________________________________
* Cases who had only one pathogen identified in stool.

E. coli:
Cases (A) Controls (B)
06 -2
06 -5
29
32
167 -1
112
137
145
125
85
56
166
64
71
113
101
51 -2
51 -4
54
83
132
165
38
40
62
58
67
72
82
142
167 -7
155
136
165