{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,13]],"date-time":"2026-03-13T21:03:10Z","timestamp":1773435790349,"version":"3.50.1"},"reference-count":43,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,5,6]]},"abstract":"<jats:p>HIV-exposed, uninfected (HEU) children are a growing population at particularly high risk of infection-related death in whom preventing diarrhea may significantly reduce under-5 morbidity and mortality in sub-Saharan Africa. A historic cohort (1999\u20132002) of Kenyan HEU infants followed from birth to 12 months was used. Maternal and infant morbidity were ascertained at monthly clinic visits and unscheduled sick visits. The Andersen\u2013Gill Cox model was used to assess maternal, environmental, and infant correlates of diarrhea, moderate-to-severe diarrhea (MSD; diarrhea with dehydration, dysentery, or related hospital admission), and prolonged\/persistent diarrhea (&gt; 7 days) in infants. HIV-exposed, uninfected infants (<jats:italic>n<\/jats:italic> = 373) experienced a mean 2.09 (95% CI: 1.93, 2.25) episodes of diarrhea, 0.47 (95% CI: 0.40, 0.55) episodes of MSD, and 0.34 (95% CI: 0.29, 0.42) episodes of prolonged\/persistent diarrhea in their first year. Postpartum maternal diarrhea was associated with increased risk of infant diarrhea (Hazard ratio [HR]: 2.09; 95% CI: 1.43, 3.06) and MSD (HR: 2.89; 95% CI: 1.10, 7.59). Maternal antibiotic use was a risk factor for prolonged\/persistent diarrhea (HR: 1.63; 95% CI: 1.04, 2.55). Infants living in households with a pit latrine were 1.44 (95% CI: 1.19, 1.74) and 1.49 (95% CI: 1.04, 2.14) times more likely to experience diarrhea and MSD, respectively, relative to those with a flush toilet. Current exclusive breastfeeding was protective against MSD (HR: 0.30; 95% CI: 0.15, 0.58) relative to infants receiving no breast milk. Reductions in maternal diarrhea may result in substantial reductions in diarrhea morbidity among HEU children, in addition to standard diarrhea prevention interventions.<\/jats:p>","DOI":"10.4269\/ajtmh.19-0705","type":"journal-article","created":{"date-parts":[[2020,2,25]],"date-time":"2020-02-25T07:01:05Z","timestamp":1582614065000},"page":"1001-1008","source":"Crossref","is-referenced-by-count":6,"title":["Maternal Diarrhea and Antibiotic Use are Associated with Increased Risk of Diarrhea among HIV-Exposed, Uninfected Infants in Kenya"],"prefix":"10.4269","volume":"102","author":[{"given":"Emily L.","family":"Deichsel","sequence":"first","affiliation":[{"name":"Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patricia B.","family":"Pavlinac","sequence":"additional","affiliation":[{"name":"Department of Global Health, University of Washington, Seattle, Washington;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dorothy","family":"Mbori-Ngacha","sequence":"additional","affiliation":[{"name":"United Nations Children\u2019s Fund (UNICEF), New York, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Judd L.","family":"Walson","sequence":"additional","affiliation":[{"name":"Department of Global Health, University of Washington, Seattle, Washington;"},{"name":"Department of Epidemiology, University of Washington, Seattle, Washington;"},{"name":"Department of Pediatrics, University of Washington, Seattle, Washington;"},{"name":"Department of Medicine, University of Washington, Seattle, Washington;"},{"name":"Child Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth","family":"Maleche-Obimbo","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carey","family":"Farquhar","sequence":"additional","affiliation":[{"name":"Department of Global Health, University of Washington, Seattle, Washington;"},{"name":"Department of Epidemiology, University of Washington, Seattle, Washington;"},{"name":"Department of Medicine, University of Washington, Seattle, Washington;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rose","family":"Bosire","sequence":"additional","affiliation":[{"name":"Center for Public Health Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Grace C.","family":"John-Stewart","sequence":"additional","affiliation":[{"name":"Department of Global Health, University of Washington, Seattle, Washington;"},{"name":"Department of Epidemiology, University of Washington, Seattle, Washington;"},{"name":"Department of Pediatrics, University of Washington, Seattle, Washington;"},{"name":"Department of Medicine, University of Washington, Seattle, Washington;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2795","reference":[{"key":"b1","series-title":"Lancet Infect Dis","first-page":"1","article-title":"Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015","volume":"3099","author":"GBD Diarrhoeal Diseases Collaborators","year":"2017"},{"key":"b2","series-title":"Lancet","doi-asserted-by":"publisher","first-page":"2151","DOI":"10.1016\/S0140-6736(12)60560-1","article-title":"Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000","volume":"379","author":"Liu","year":"2012"},{"key":"b3","series-title":"Gastroenterology","doi-asserted-by":"publisher","first-page":"1156","DOI":"10.1053\/j.gastro.2010.05.076","article-title":"Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children","volume":"139","author":"Moore","year":"2010"},{"key":"b4","series-title":"Am J Epidemiol","doi-asserted-by":"publisher","first-page":"166","DOI":"10.1093\/aje\/kwf179","article-title":"Effects of acute diarrhea on linear growth in Peruvian children","volume":"157","author":"Checkley","year":"2003"},{"key":"b5","series-title":"Lancet","doi-asserted-by":"publisher","first-page":"564","DOI":"10.1016\/S0140-6736(02)07744-9","article-title":"Effect of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study","volume":"359","author":"Berkman","year":"2002"},{"key":"b6","series-title":"Lancet Glob Health","doi-asserted-by":"publisher","first-page":"e255","DOI":"10.1016\/S2214-109X(18)30045-7","article-title":"Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years","volume":"6","author":"Troeger","year":"2018"},{"key":"b7","series-title":"Number of People Living with HIV-Young Women","author":"UNAIDS","year":"2018"},{"key":"b8","series-title":"UNAIDS Fact Sheet","first-page":"18","author":"Joint United Nations Programme on HIV\/AIDS (UNAIDS)","year":"2016"},{"key":"b9","series-title":"2015 Progress Report on the Global Plan","author":"Joint United Nations Programme on HIV\/AIDS (UNAIDS)","year":"2015"},{"key":"b10","series-title":"Pediatr Infect Dis J","doi-asserted-by":"publisher","first-page":"536","DOI":"10.1097\/01.inf.0000129692.42964.30","article-title":"Predictors of early mortality in a cohort of human immunodeficiency virus type 1-infected african children","volume":"23","author":"Obimbo","year":"2004"},{"key":"b11","series-title":"East Afr Med J","first-page":"447","article-title":"Predictors of mortality in HIV-1 exposed uninfected post-neonatal infants at the Kenyatta National Hospital, Nairobi","volume":"82","author":"Gichuhi","year":"2005"},{"key":"b12","series-title":"Lancet","doi-asserted-by":"publisher","first-page":"209","DOI":"10.1016\/S0140-6736(13)60844-2","article-title":"Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study","volume":"382","author":"Kotloff","year":"2013"},{"key":"b13","series-title":"Ann Stat","first-page":"1100","article-title":"Cox\u2019s regression model for counting processes: a large sample study","volume":"10","author":"Andersen","year":"1982"},{"key":"b14","series-title":"Curr Opin Infect Dis","doi-asserted-by":"publisher","first-page":"451","DOI":"10.1097\/QCO.0000000000000096","article-title":"Global burden of childhood diarrhea and interventions","volume":"27","author":"Das","year":"2014"},{"key":"b15","series-title":"Am J Epidemiol","doi-asserted-by":"publisher","first-page":"776","DOI":"10.1093\/oxfordjournals.aje.a009354","article-title":"Risk factors for diarrheal duration","volume":"146","author":"Mirza","year":"1997"},{"key":"b16","series-title":"Am J Trop Med Hyg","doi-asserted-by":"publisher","first-page":"250","DOI":"10.4269\/ajtmh.14-0727","article-title":"The influence of episode severity on caregiver recall, care seeking, and treatment of diarrhea among children 2\u201359 months of age in Bihar, Gujarat, and Uttar Pradesh, India","volume":"93","author":"Lamberti","year":"2015"},{"key":"b17","series-title":"Vaccine","doi-asserted-by":"publisher","first-page":"A173","DOI":"10.1016\/j.vaccine.2011.08.004","article-title":"Five-year cohort study on the burden of hospitalisation for acute diarrhoeal disease in African HIV-infected and HIV-uninfected children: potential benefits of rotavirus vaccine","volume":"30","author":"Groome","year":"2012"},{"key":"b18","series-title":"J Pediatr","doi-asserted-by":"publisher","first-page":"54","DOI":"10.1016\/j.jpeds.2016.04.088","article-title":"Maternal antiretroviral therapy is associated with lower risk of diarrhea in early childhood","volume":"175","author":"Sztam","year":"2016"},{"key":"b19","series-title":"BMC Public Health","doi-asserted-by":"publisher","first-page":"220","DOI":"10.1186\/1471-2458-12-220","article-title":"Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review","volume":"12","author":"Fischer Walker","year":"2012"},{"key":"b20","series-title":"Lancet","doi-asserted-by":"publisher","first-page":"243","DOI":"10.1016\/S0140-6736(07)61690-0","article-title":"Maternal and child undernutrition: global and regional exposures and health consequences","volume":"371","author":"Black","year":"2008"},{"key":"b21","series-title":"Int J Epidemiol","doi-asserted-by":"publisher","first-page":"i193","DOI":"10.1093\/ije\/dyq035","article-title":"Water, sanitation and hygiene for the prevention of diarrhoea","volume":"39","author":"Cairncross","year":"2010"},{"key":"b22","series-title":"Cochrane Database Syst Rev","first-page":"CD007180","article-title":"Interventions to improve disposal of human excreta for preventing diarrhoea","volume":"6","author":"Clasen","year":"2010"},{"key":"b23","series-title":"Lancet Glob Health","doi-asserted-by":"publisher","first-page":"e699","DOI":"10.1016\/S2214-109X(17)30217-6","article-title":"Effect of community health clubs on child diarrhoea in western Rwanda: cluster-randomised controlled trial","volume":"5","author":"Sinharoy","year":"2017"},{"key":"b24","series-title":"Am J Trop Med Hyg","doi-asserted-by":"publisher","first-page":"318","DOI":"10.4269\/ajtmh.2011.11-0140","article-title":"Drinking water quality, feeding practices, and diarrhea among children under 2 years of HIV-positive mothers in peri-urban Zambia","volume":"85","author":"Peletz","year":"2011"},{"key":"b25","series-title":"Trop Med Int Heal","doi-asserted-by":"publisher","first-page":"1156","DOI":"10.1111\/j.1365-3156.2010.02595.x","article-title":"Use of nutritional and water hygiene packages for diarrhoeal prevention among HIV-exposed infants in Lilongwe, Malawi: an evaluation of a pilot prevention of mother-to-child transmission post-natal care service","volume":"15","author":"Xue","year":"2010"},{"key":"b26","series-title":"Clin Infect Dis","first-page":"575","article-title":"Co-trimoxazole prophylaxis, asymptomatic malaria parasitemia, and infectious morbidity in HIV-exposed uninfected infants in Malawi: the BAN study","volume":"65","author":"Davis","year":"2016"},{"key":"b27","series-title":"Int Health","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1093\/inthealth\/ihu061","article-title":"Maternal multivitamin supplementation reduces the risk of diarrhoea among HIV-exposed children through age 5 years","volume":"6","author":"Khavari","year":"2014"},{"key":"b28","author":"World Health Organization","year":"2001"},{"key":"b29","series-title":"Dan Med Bull","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1186\/1471-2458-11-S3-S15","article-title":"The epidemiology of diarrhoeal diseases in early childhood","volume":"47","author":"Molbak","year":"2000"},{"key":"b30","series-title":"BMC Public Health","doi-asserted-by":"publisher","first-page":"S15","DOI":"10.1097\/QAI.0b013e3181bd5a47","article-title":"Breastfeeding and the risk for diarrhea morbidity and mortality","volume":"11","author":"Lamberti","year":"2011"},{"key":"b31","series-title":"J Acquir Immune Defic Syndr","first-page":"6","article-title":"Frequency of gastroenteritis and gastroenteritis-associated mortality with early weaning in HIV-1-uninfected children born to HIV-infected women in Malawi","volume":"53","author":"Kafulafula","year":"2010"},{"key":"b32","series-title":"Front Immunol","doi-asserted-by":"publisher","first-page":"399","DOI":"10.1186\/s12879-015-0766-6","article-title":"The impact of HIV-1 infection and exposure on natural killer (NK) cell phenotype in Kenyan infants during the first year of life","volume":"3","author":"Slyker","year":"2012"},{"key":"b33","series-title":"BMC Infect Dis","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1086\/498029","article-title":"Impact of elevated maternal HIV viral load at delivery on T-cell populations in HIV exposed uninfected infants in Mozambique","volume":"15","author":"de Deus","year":"2015"},{"key":"b34","series-title":"Clin Infect Dis","first-page":"1654","article-title":"Does severity of HIV disease in HIV-infected mothers affect mortality and morbidity among their uninfected infants?","volume":"41","author":"Kuhn","year":"2005"},{"key":"b35","series-title":"Prevention of Mother-to-Child Transmission. Global Health Observatory Data Repository","doi-asserted-by":"publisher","DOI":"10.4269\/ajtmh.16-0898","author":"World Health Organization","year":"2018"},{"key":"b36","series-title":"Am J Trop Med Hyg","doi-asserted-by":"publisher","first-page":"248","DOI":"10.1017\/S1368980013000499","article-title":"Factors associated with the duration of moderate-to-severe diarrhea among children in rural western Kenya enrolled in the global enteric multicenter study, 2008\u20132012","volume":"97","author":"Schilling","year":"2017"},{"key":"b37","series-title":"Public Health Nutr","doi-asserted-by":"publisher","first-page":"1548","DOI":"10.1136\/pgmj.2003.011973","article-title":"Maternal HIV infection and other factors associated with growth outcomes of HIV-uninfected infants in Entebbe, Uganda","volume":"16","author":"Muhangi","year":"2013"},{"key":"b38","series-title":"Postgrad Med J","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1093\/ije\/dyx272","article-title":"Effect of maternal antibiotics on breast feeding infants","volume":"80","author":"Mathew","year":"2004"},{"key":"b39","series-title":"Int J Epidemiol","first-page":"561","article-title":"Maternal antibiotic exposure during pregnancy and hospitalization with infection in offspring: a population-based cohort study","volume":"47","author":"Miller","year":"2018"},{"key":"b40","series-title":"J Pediatr","first-page":"153.e1","article-title":"Antibiotics in pregnancy increase children\u2019s risk of otitis media and ventilation tubes","volume":"183","author":"Pedersen","year":"2017"},{"key":"b41","series-title":"Sci Rep","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1371\/journal.pone.0081307","article-title":"Impact of intrapartum and postnatal antibiotics on the gut microbiome and emergence of antimicrobial resistance in infants","volume":"9","author":"Tapiainen","year":"2019"},{"key":"b42","series-title":"PLoS One","first-page":"e81307","article-title":"Exclusive breastfeeding, diarrhoeal morbidity and all-cause mortality in infants of HIV-infected and HIV uninfected mothers: an intervention cohort study in KwaZulu Natal, South Africa","volume":"8","author":"Rollins","year":"2013"},{"key":"b43","series-title":"Matern Child Nutr","first-page":"e12861","article-title":"Birth size and early pneumonia predict linear growth among HIV\u2010exposed uninfected infants","volume":"15","author":"Deichsel","year":"2019"}],"container-title":["The American Journal of Tropical Medicine and Hygiene"],"original-title":[],"link":[{"URL":"https:\/\/www.ajtmh.org\/view\/journals\/tpmd\/102\/5\/article-p1001.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.ajtmh.org\/downloadpdf\/journals\/tpmd\/102\/5\/article-p1001.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/www.ajtmh.org\/downloadpdf\/journals\/tpmd\/102\/5\/article-p1001.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,2,6]],"date-time":"2023-02-06T18:13:08Z","timestamp":1675707188000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ajtmh.org\/view\/journals\/tpmd\/102\/5\/article-p1001.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,5,6]]},"references-count":43,"journal-issue":{"issue":"5"},"URL":"https:\/\/doi.org\/10.4269\/ajtmh.19-0705","relation":{},"ISSN":["0002-9637","1476-1645"],"issn-type":[{"value":"0002-9637","type":"print"},{"value":"1476-1645","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,5,6]]}}}