Abstract
Giardia are among the most common enteropathogens detected in children in low-resource settings. We describe here the epidemiology of infection with Giardia in the first 2 years of life in the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED), a multisite birth-cohort study. From 2089 children, 34916 stool samples collected during monthly surveillance and episodes of diarrhea were tested for Giardia using an enzyme immunoassay. We quantified the risk of Giardia detection, identified risk factors, and assessed the associations with micronutrients, markers of gut inflammation and permeability, diarrhea, and growth using multivariable linear regression. The incidence of at least 1 Giardia detection varied according to site (range, 37.7%-96.4%) and was higher in the second year of life. Exclusive breastfeeding (HR for first Giardia detection in a monthly surveillance stool sample, 0.46 [95% confidence interval (CI), 0.28-0.75]), higher socioeconomic status (HR, 0.74 [95% CI, 0.56-0.97]), and recent metronidazole treatment (risk ratio for any surveillance stool detection, 0.69 [95% CI, 0.56-0.84]) were protective. Persistence of Giardia (consecutive detections) in the first 6 months of life was associated with reduced subsequent diarrheal rates in Naushahro Feroze, Pakistan but not at any other site. Giardia detection was also associated with an increased lactulose/mannitol ratio. Persistence of Giardia before 6 months of age was associated with a -0.29 (95% CI, -0.53 to -0.05) deficit in weight-for-age z score and -0.29 (95% CI, -0.64 to 0.07) deficit in length-for-age z score at 2 years. Infection with Giardia occurred across epidemiological contexts, and repeated detections in 40% of the children suggest that persistent infections were common. Early persistent infection with Giardia, independent of diarrhea, might contribute to intestinal permeability and stunted growth.
Highlights
Giardia lamblia, known as Giardia duodenalis and Giardia intestinalis, is the most common etiology of intestinal parasitic infection in the first 2 years of life in low-resource settings
Giardia infection is associated with disrupted villus architecture [16], an elevated lactulose/mannitol ratio [17, 18], and zinc and vitamin A deficiencies [19,20,21], which suggests gut dysfunction and inadequate nutrient uptake
Giardia positivity by microscopy was 21% less likely if the stool was watery or liquid than if it was soft or formed (risk ratio [RR], 0.79 [95% confidence interval (CI), 0.68–0.90]), but we found no association between stool consistency and enzyme immunoassay (EIA) results (RR, 0.94 [95% CI, 0.86–1.03])
Summary
Known as Giardia duodenalis and Giardia intestinalis, is the most common etiology of intestinal parasitic infection in the first 2 years of life in low-resource settings. Giardia infection is associated with disrupted villus architecture [16], an elevated lactulose/mannitol ratio (a marker of intestinal permeability) [17, 18], and zinc and vitamin A deficiencies [19,20,21], which suggests gut dysfunction and inadequate nutrient uptake. These associations, have been inconsistent and limited. We describe here the epidemiology of infection with Giardia in the first 2 years of life in the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED), a multisite birth-cohort study
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