Epidemiology and Infection

Review Article

Part III. Analysis of data gaps pertaining to enterotoxigenic Escherichia coli infections in low and medium human development index countries, 1984–2005

S. K. GUPTAa1 c1, J. KECKa2, P. K. RAMa3, J. A. CRUMPa1, M. A. MILLERa4 and E. D. MINTZa1

a1 Enteric Diseases Epidemiology Branch, National Center for Zoonotic, Vectorborne, and Enteric Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA

a2 University of Minnesota Medical School, Minneapolis, MN, USA

a3 School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA

a4 Fogarty International Center, National Institutes of Health, Bethesda, MD, USA


Enterotoxigenic Escherichia coli (ETEC) is a common cause of profuse watery diarrhoea in the developing world, often leading to severe dehydration or death. We found only 15 population-based studies in low and medium human development index (HDI) countries from 1984 to 2005 that evaluate disease incidence. Reported incidence ranged from 39 to 4460 infections/1000 persons per year. The peak incidence of ETEC appeared to occur between ages 6 and 18 months. A median of 14% (range 2–36%) of diarrhoeal specimens were positive for ETEC in 19 facility- and population-based studies conducted in all age groups and 13% (range 3–39%) in 51 studies conducted in children only. Heat-labile toxin (LT)-ETEC is thought to be less likely to cause disease than heat-stable toxin (ST)-ETEC or LT/ST-ETEC. Because population-based studies involve enhanced clinical management of patients and facility-based studies include only the most severe illnesses, reliable data on complications and mortality from ETEC infections was unavailable. To reduce gaps in the current understanding of ETEC incidence, complications and mortality, large population-based studies combined with facility-based studies covering a majority of the corresponding population are needed, especially in low-HDI countries. Moreover, a standard molecular definition of ETEC infection is needed to be able to compare results across study sites.

(Accepted June 30 2007)

(Online publication August 09 2007)


c1 Author for correspondence: S. K Gupta, M.D., CDC Global AIDS Program Central America and Panama, Apartado Postal 3013, Correo Nacional, Tegucigalpa, Honduras, Central America. (Email: scg7@cdc.gov)


This is the third of three papers, appearing in successive issues of the Journal, reviewing the analysis of data gaps pertaining to infections in low and medium human development index (HDI) countries.