{
  "abstract": "Diarrhoea remains a major problem among children in low- and middle-income countries, driven by multiple pathogens including rotavirus, Shigella and enterotoxigenic Escherichia coli (ETEC). Rotavirus vaccines have notably reduced diarrhoea deaths. However, the health consequences associated with Shigella and ETEC, along with rising antimicrobial resistance (AMR), have prompted the WHO to prioritise vaccine development against these two pathogens. Understanding their disease burden is crucial for guiding this effort and informing preparedness for vaccine adoption.We conducted a systematic review and meta-analysis of primary peer-reviewed literature to establish the prevalence, subtypes and AMR patterns of Shigella and ETEC-associated diarrhoea in Ethiopia, Kenya and Malawi, where the authors have established a multidisciplinary research programme addressing gastrointestinal infections. We searched in PubMed, among other databases, for English-language publications from 1 January 2000 to 28 July 2023. The meta-analysis used a random effects model to estimate pooled prevalence.43 studies were included. Malawi exhibited a higher estimated prevalence of Shigella (24% (95% CI 10% to 39%)) than Ethiopia and Kenya (both with an estimated prevalence of 6%), most likely explained by the application of sensitive, molecular detection methods in Malawi. The overall pooled prevalence of Shigella was 8% (95% CI 6% to 9%). Malawi again displayed higher ETEC prevalence (24% (95% CI 14% to 33%)) compared with Kenya (7% (95% CI 5% to 10%)), with no studies of ETEC identified from Ethiopia. The overall pooled prevalence of ETEC was 11% (95% CI 6% to 15%). Shigella flexneri was the major species of Shigella, and heat-stable ETEC was highly prevalent. Shigella species displayed resistance to several classes of antibiotics, including penicillins, tetracyclines, macrolides and sulphonamides, but susceptibility to fluoroquinolones and cephalosporins.These findings underscore the need for countries to generate updated disease burden estimates for Shigella and ETEC through epidemiologically robust studies that use sensitive diagnostic methods in preparation for vaccine introduction.",
  "authors": [
    {
      "affiliations": [
        "Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK"
      ],
      "name": "Chikondi Andrew Mwendera"
    },
    {
      "affiliations": [
        "Addis Ababa University College of Health Sciences, Addis Ababa, Oromia, Ethiopia"
      ],
      "name": "Mengistu Yilma"
    },
    {
      "affiliations": [
        "KEMRI, Nairobi, Nairobi, Kenya"
      ],
      "name": "Celestine Wairimu"
    },
    {
      "affiliations": [
        "KEMRI, Nairobi, Nairobi, Kenya"
      ],
      "name": "Kelvin Kering"
    },
    {
      "affiliations": [
        "Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Blantyre, Malawi"
      ],
      "name": "Edson Mwinjiwa"
    },
    {
      "affiliations": [
        "Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya"
      ],
      "name": "James Ngumo Kariuki"
    },
    {
      "affiliations": [
        "Addis Ababa University College of Health Sciences, Addis Ababa, Oromia, Ethiopia"
      ],
      "name": "Daniel Asrat"
    },
    {
      "affiliations": [
        "Addis Ababa University College of Health Sciences, Addis Ababa, Oromia, Ethiopia"
      ],
      "name": "Amha Mekasha"
    },
    {
      "affiliations": [
        "Pathology, Kamuzu University of Health Sciences, Blantyre, Malawi"
      ],
      "name": "Chisomo Msefula"
    },
    {
      "affiliations": [
        "KEMRI, Nairobi, Nairobi, Kenya"
      ],
      "name": "Samuel Kariuki"
    },
    {
      "affiliations": [
        "Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK",
        "Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Blantyre, Malawi"
      ],
      "name": "Jen Cornick"
    },
    {
      "affiliations": [
        "National Institute for Health and Care Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK"
      ],
      "name": "Helen Clough"
    },
    {
      "affiliations": [
        "Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK"
      ],
      "name": "Neil French"
    },
    {
      "affiliations": [
        "Department of Epidemiology of Microbial Diseases, Yale University, New Haven, Connecticut, USA"
      ],
      "name": "Virginia Pitzer"
    },
    {
      "affiliations": [
        "Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Blantyre, Malawi",
        "Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, Merseyside, UK"
      ],
      "name": "Khuzwayo C Jere"
    },
    {
      "affiliations": [
        "Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, Merseyside, UK"
      ],
      "name": "Daniel Hungerford"
    },
    {
      "affiliations": [],
      "name": "GHRG-GI Consortium"
    }
  ],
  "title": "Burden of Shigella and enterotoxigenic Escherichia coli infections among children under 5 years in Ethiopia, Kenya and Malawi: a systematic review and meta-analysis",
  "uid": "2ce34a6f-320d-56ac-93ec-7da0c008a57f"
}