Epidemic Shigella dysentery in children in northern KwaZulu-Natal

Objectives. To describe the epidemiology, clinical features, management and outcome of children with Shigella dysenteriae type 1 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 acid 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.