The genus Campylobacter is a zoonotic foodborne pathogen that causes diarrheal disease; the two major species are Campylobacter jejuni and Campylobacter coli [1]. Campylobacter jejuni is responsible for over 90% of human campylobacteriosis and is frequently isolated from poultry (81%) while C. coli causes less than 10% of human disease and is most frequently isolated from pigs (100%) [2] [3].

Campylobacteriosis is a problem and an economic burden to human population worldwide with an estimated 96 million cases annually, exceeding those of salmonellosis, shigellosis and E. coli: 0157H7 combined [4]. It is the third most common cause of hospitalization globally after Rotavirus and Salmonella infections and is associated with the loss of up to 7.5 million disability-adjusted life years [5] [6]. Human Campylobacter infections are categorized into gastrointestinal conditions, including inflammatory bowel diseases (IBD), diarrhea, Barrett’s esophagus and colorectal cancer [7] and extragastrointestinal manifestations including bacteremia, lung infections, brain abscesses, meningitis, and reactive arthritis [8]. Incubation period is 1 - 10 days and clinical symptoms range from acute abdominal pain, watery diarrhoea, fever, nausea, vomiting, headache and muscle pain [9] which may persist for a week or longer [10]. The severity of illness varies from mild malaise to dehydration sufficient to warrant hospitalization and can be life-threatening [11].

Although campylobacteriosis is largely perceived as a foodborne infection with consumption and handling of poultry and poultry-related products being the major source of all Campylobacter infections [12], there is increasing evidence of additional routs of transmission including direct contact with other farm animals, consumption of undercooked foods and contaminated environment [13] [14]. Wild birds also play a role as reservoirs and can spread Campylobacter to humans through the environment [15]. Human-to-human transmission has been observed, although at low frequencies [16].

The epidemiology of Campylobacter enteritis differs between high- and low-income countries [17]. In high-income countries, clinical signs are symptomatic and occur in all age groups [18] whereas in low resource settings, most cases are asymptomatic with young children being more predisposed due to underdeveloped immunity. Adults acquire a level of protective immunity following repeated exposure and become predisposed when immunity gets low at senior age. Globally, the distribution of Campylobacter is attributed to asymptomatic colonization of the intestinal tract in a wide range of livestock species, use of animals manure, drinking contaminated water and poor hygiene conditions [19] [20] [21]. Studies have suggested that the incidence of Campylobacter enteritis is on the rise globally [22]. This increase has been noted much more in developed countries due to improved awareness and advances in detection practices [23].

In low and middle income countries (LMICs) such as Kenya, sources of Campylobacter infections have been less well documented due to lack of awareness and advances in detection practices to undertake national surveillance programmes and build a National epidemiological data banks of the disease. However, the available data indicate that the infection is endemic and on the rise [23]. The limited reports on Campylobacter are estimates from laboratory-based surveillance studies of pathogens responsible for diarrhoea [24] [25]. In Tanzania, the prevalence of human Campylobacter enteritis was reported at 21.6% [26] and between 12% - 12.6% in Kenya [27]. Because of the importance of this disease and the rise in poultry farming in Kenya, this study was carried out with an aim of determining the prevalence and homestead risk practices associated with Campylobacter infection in diarrheal patients in Busia County, a region marked by high prevalence of HIV and proliferation of small-holder livestock production with over 95% of households keeping poultry [28].

In this study, the high number of hospital visits from children < 5 years of age (81.4%) suggests diarrhea, which Campylobacter is mostly associated with, was largely a pediatric disease in this region.

Our overall prevalence of Campylobacter infection among diarrheal patients was 11.6%, comprising of 89.2% C. jejuni and 10.8% C. coli. This prevalence was higher compared to reports from studies in Nairobi 3.1% [31] and Kisii 5.8% [35] in Kenya, Tanzania 9.3% [36] and Egypt 9% [20], consistent to those reported from Ethiopia 11.6% [37], and lower than those found in Nigeria 16.5% [38] and Algeria 17.7% [39]. These variations may arise due to differences in the set predictive values of test systems, social and cultural practices, geographical location, population immunity as well as differences in public health standards, intervention strategies, surveillance systems, food safety practices, and the prevalence of Campylobacter in natural reservoirs in different regions [23] [40].

From an African perspective, where Campylobacter is endemic and chicken meat on top feeding list, our reported prevalence (11.6%) in human is considered significant especially in this era of HIV/AIDS. Although this study was limited in establishing the role of HIV in Campylobacter infection, it is important to consider Campylobacter infection in a different perspective because of its close association with HIV/AIDS. Studies have predicted an upsurge of several diseases associated with immune-suppression and reported incidences of Campylobacter infection in patients with HIV/AIDS as 39 times higher than the infection rate in the general population [41]. There might be a possible future increase of Campylobacter infection since HIV infection has been reported high (7.7%) in this area with an incidence of 52,800 cases across all ages annually [42].

Although the diagnosis and treatment of diarrhea was not captured in our questionnaire, the health management strategies adopted by the Ministry of Health (MoH) Kenya since 2010 on appropriate measures for treatment and management of diarrheal diseases both in hospitals and home based care at community level recommends ORS and Zinc for mild diarrhea. Antibiotics are rarely given unless in severe cases of dysentery, cholera, giardiasis and amoebiasis. Detection of these diarrheal etiologies require proper laboratory systems which are absent in most hospitals in Buisa and most patients are treated empirically [43].

Even though there was a general downward trend of prevalence of Campylobacter infection from children < 2 years (13.7%) through 2 - 5 years (10.2%) and >5 years (9.4%), this general progressive decline of the infection with age might be due to age-related acquisition of protective immunity as a result of close proximity and frequent interactions with livestock hence frequent exposure to Campylobacter infection [17] [18] [43]. However, other studies have shown a decline of this immunity at an advanced age > 60 years [44].

This study analyzed the potential risk exposures associated with household practices from several exposure variables of social demographic, clinical, economic and behavioral factors considered on the basis of biological plausibility and previous knowledge on the risks associated with Campylobacter infection [13] [20] [21]. Our findings suggest that homestead practices of poultry farming, eating chicken meat, drinking raw milk, breast feeding, use of untreated pond water, contact with infected diarrheal individuals and domestic pets, use of same food cutting board without washing with soap, use of toilets, residential area and gender were significantly associated with human Campylobacter infection in Busia County. Although this study did not comprehensively evaluate all the plausible social economic factors, the few that were analyzed did not yield any significant association with Campylobacter infection.

Majority of the participants presented with fever (77.7%) and vomiting (53.8%) as the main clinical signs. Similarly none of the analyzed clinical signs and symptoms were found to be associated with Campylobacter infection. This is likely because majority of Campylobacter infections in low resource settings are mainly asymptomatic [22].

Poultry farming was significantly associated with Campylobacter infection across all age divide of the participants. This might be because of the fact that most of the household livelihoods in Busia County where the study was conducted, depend majorly on livestock farming with chicken being the most commonly kept livestock that offers quick sale and food in an environment where water sanitation and hygiene (WASH) pose a lot of challenges in the livestock sector [29]. Campylobacter enters food chain through poultry regarded as the main source through which transmissions occur and once established in chicken caeca, the number proliferates rapidly to high levels (109 CFU/g) and can remain carriers until slaughter [45] [46]. During this period, high number of Campylobacter are shaded through feces and contaminates the surrounding environment where the birds live and in turn, allow the pathogen transmission to humans through fecal oral rout [47]. Likewise, there has been increasing evidence that contact with farm animals offer significant risk exposures to human Campylobacter infection [13] [48] with poultry being the major source of food-related transmission and reservoir of Campylobacter species to humans [49]. In addition, source-attribution studies have linked zoonotic transmission of human Campylobacter to poultry exposures and consumption of chicken, dairy products and contaminated water [13] [14] [17].

We noted at the same time that household use and drinking of untreated pond water was a significant risk for Campylobacter infection among children < 5 years. This environmental surface water (pond) is served by several contaminated streams from free-range small hold livestock farm systems and can remain stagnant for a long period of time. Consequently such cumulative contamination by Campylobacter species may present potential reservoir and transmitting vehicles for Campylobacter [50] [51] [52] [53]. Studies have shown many possible sources of Campylobacter infection in humans including contaminated water [54]. In Kenya, approximately 17,100 children under 5 years die each year from diarrhea, with 90% of these deaths being attributed to poor water, sanitation and hygiene [55]. According to Busia County Development Plan, 2018-2022, the main source of drinking water is from borehole (46%), other sources including springs, rivers, piped and pond water. Apart from urban treated water supplied by Busia Water and Sewerage Company with a supply capacity of only 12.5%, the larger percentage of water used is untreated. Mothers or caregivers possibly struggle for clean and safe water in this area and a number of them likely end up using untreated pond water to care for children whose immunity may have not developed as much.

Female children < 5 years were more at risk of Campylobacter infection. Similarly, studies on diarrheal correlates associated with enteric bacterial infections in Busia and Muranga Counties in Kenya showed that female between 6 - 36 months were twice more likely to be infected with enteric bacterial pathogens than their male counterparts [56] [57]. Likewise in rural Sudan, female children < 5 years were more at risk [58]. Although female subjects were found to be significantly more at risk of Campylobacter infections, other studies have contrasting reports with unclear reasons [59] [60]. Sex specific age differences in immunity may exist but have not been elaborately documented. More investigations are recommended for better understanding on factors such as immunological, demographic and behavioral associated with sex specific differences across the globe.

Although we did not directly assess the risk associated with each and every step in handling and preparation of food in household kitchens, assessment of use of same food cutting board without proper wash was picked as a significant risk for children < 2 years. Care givers involved in food preparation for these children were three times (AOR 3.32, P = 0.014) more likely to predispose their children to Campylobacter infection and this is consistent with other findings [61]. In Kenya, complementary feeding is introduced after 6 months though some mothers introduce weaning earlier. It is possible that there might have been lack of personal hygiene and inadequate cleansing of food surfaces by the mothers or caregivers and subsequent cross-contamination of Campylobacter during food preparation from raw food. Similarly, it has been shown that unhygienic food preparation, food storage and subsequent feeding of infants can aggravate transmission of diarrheal pathogens and pose great risk to this age cohort [62]. Otherwise self-contamination and cross transmission of Campylobacter infection may be minimize through personal and kitchen hygiene practices at household level.

Breast feeding and frequent use of toilet had protective effect among children < 2 years. This might be due to transfers of maternal antibodies in breast milk with health befits to the child. Open defecation predisposes water and food to fecal contamination more so when it rains and may increase the risk of Campylobacter transmission. Frequent use of toilets partly takes care of this public health problem and ensures standards necessary to break the vicious cycle of diarrheal pathogens spread from persons infected to the environment hence minimize the transmission of Campylobacter infection and offer protection to these children [39]. In addition, this study found a fairly high literacy level among the participants with 91% having at least acquired primary school education. This may have contributed towards adherence to the recommended WASH practices such as frequent usage of toilets.

Many people keep cats and dogs at home as pets and for security reasons and our study showed this interaction was significantly associated with Campylobacter infection in children of 2 - 5 years (OR 5.72, P = 0.016). This might have been due to their playful nature at this age and a likelihood of being physically closer to these pets and more likely than others to contaminate and put their fingers or other items into their mouths which might have aggravated the transmission of the infection. Our finding is similar to previous studies performed in Kenya [63] which showed that the incident of Campylobacter infection was significantly higher in children who had contact with domestic animals and more so in those who keep dogs and cats as pets [64].

On dietary habits reported at household level, consumption of chicken was more frequent (78.2%) of all the foods considered and was significantly associated with Campylobacter infection in children of 2 - 5 years. This age is explorative, very playful and is common when self-feeding practices occur with subsequent development of immunity due to exposures. When chicken is prepared under unhygienic way or consumed when under-cooked, it can cause Campylobacter infection and is considered the most common cause of diarrheal outbreaks in Europe [65]. Although Campylobacter infection rate was the same among rural and urban dwellers, children between 2 - 5 years of age from urban were more protected from the infection 0.47 (0.20 - 0.82) P = 0.041 as compared to those from rural. The expected improved environment and water, sanitation and hygiene (WASH) infrastructure in urban areas may have played a role and came with health benefits to these children [66].

Drinking raw milk was the third most used food item at home (70.3%) and was a risk in >5 years. Raw unpasteurized milk has largely been implicated in several Campylobacter infection and outbreaks [67] [68] [69]. Elsewhere, genomic analyses showed that the presence of Campylobacter species in milk was attributed to fecal contamination [70].

We found exposure to household member with diarrhea a risk to those > 5 years of age (AOR 4.72, P = 0.006). The mode of transmission here is thought to be through fecal-oral root from either person-to-person or exposure to a common source of infection within the homestead not connected to the exposures under investigation. We could not establish information about the exposures to risk factors associated with other household members in our study. However, similar studies have implicated the contributions of person-to-person transmission of Campylobacter infection and outbreaks [65] [71].

The absence of association between Campylobacter infection and clinical symptoms has been reported in low income countries [72] [73]. This may be due to development of defensive immunity characterized with developing countries, high sensitivity of the PCR method in detecting low number of live and dead bacteria, all of which are neither indicative of clinical disease. Furthermore, the detected Campylobacter can also reflect convalescent phase as excretion of Campylobacter may last up to 10 weeks after infection [17]. Other factors considered without significant association included medical history on expanded immunization program (EIP) vaccine coverage, education, contact with wildlife, local and or International travel, types of house lived in and any long term medication and immunosuppressive treatment based on a 4-week history.

The present study found that diarrhea is mainly a pediatric disease and children < 5 years are more predisposed to homestead related risk activities associated with Campylobacter infection. Campylobacter jejuni was found to be the leading cause of Campylobacter infections in the study area. Ruling out Campylobacter infection in patients with diarrhea would help in proper management more so in children who are most affected, and where HIV prevalence is high as in most developing countries. Personal hygiene practices and proper animal husbandry especially where livestock-human interaction is common is important. Further studies are required on sex specific age difference, social economic factors and the role played by the environment and other domestic animals in the transmission of Campylobacter infection. This would advance knowledge and understanding on source attribution and transmission dynamics for effective control and management of the infection.

We wish to thank the patients and County health officials for their cooperation during the study period. We appreciate the entire clinical and laboratory staff both in Busia County Hospital, Centre for Microbiology Research, Nairobi and International Livestock Research Institute Busia for their hard work and diligence in supporting this study. We thank the Director General KEMRI for partly funding this study through the Internal Research Grant (IRG-Ref. No. KEMRI/CONF/FIN/6/101).

The datasets used and analyzed during this study are available from the corresponding author on request.

The study was approved by the Scientific Ethical Review Unit (SERU), Kenya Medical Research Institute (KEMRI protocol No. 3320). Permission was obtained from County Health offices and Hospital administrators. Written informed consent was obtained from the study patients or guardians of minors/study patients. The results were shared with the duty physician for appropriate patient treatment and management.

No author has any competing interest to declare.

Ouko, T.T., Nyerere, A.K., Njeru, J.M., Fèvre, E.M. and Kariuki, S. (2021) Prevalence and Risk Factors Associated with Campylobacter Infection in Diarrheal Patients in Busia County, Kenya. Advances in Microbiology, 11, 657-680. https://doi.org/10.4236/aim.2021.1111048

KENYA MEDICAL RESEARCH INSTITUTE/ILRI

Questionnaire on prevalence and risk factors associated with Campylobacter infection in diarrheal patients in Busia County, Kenya.

Date of recruitment ……..……………… Patient id/Barcode …….……….

Personal Data:

Date of birth ………………………..…… Place of Residence __________

Gender ☐ Male ☐ Female Contact Tel/Address ……………

1. Occupation: What is your current occupation/workplace

Business

Unemployed

Poultry farming

Employed

Others ______________

2. Educational level: Which is your highest level of education?

None

Primary

Secondary

Tertiary

3. Clinical signs and symptoms

Onset of diarrhea …………………days. Temperature________ (˚C).

During illness, was there any of the following symptoms? Please tick all relevant answers

Key: DK/NS: don’t know/Not sure Yes No DK/NS

Vomiting………………….…...………………… ☐ ☐ ☐

Diarrhoea……………………..…………………. ☐ ☐ ☐

Stomach Cramps…….….….................................. ☐ ☐ ☐

Fever……………………….……………………. ☐ ☐ ☐

Chills……………………….….……………….. ☐ ☐ ☐

Headache………………..…...………………… ☐ ☐ ☐

Fatigue……………………….. ………………… ☐ ☐ ☐

Consistency of stool Mucoid ………………….. ☐ ☐ ☐

Bloody ……………….….. ☐ ☐ ☐

Watery ………………….. ☐ ☐ ☐

Foul smell ………………... ☐ ☐ ☐

‒ Were you/was your child) given any antibiotics? ☐ ☐ ☐

‒ When did you/your child diarrhea last? ______ hrs. How many times/day…

‒ Vaccine compliant …………………………… ☐ ☐ ☐

4. Environmental Risk Factors

Which of the following describes where you live?

• City/Urban

• Rural/Village

• Type of water used:

Which type of water do you usually use:

Borehole

Tap

River

Pond

Lake

5. Dietary habit: Do you/your child usually eat the following (>3/week)

Yes No DK/NS

Chicken

Pork

Beef

Raw milk

Eggs or food containing eggs

Fish

Raw fruits/fruit salad/vegetables

Breast milk

• Where do you usually purchase food for home consumption?

Grocery stores

Individual farmyard

Local market

Others, specify …….

• Do you have cutting board for food?

Yes

No

If yes, how do you clean it before use?

Rinse with water

Wash with detergent/soap then clean with water

Others, specify…………………….

6. Exposure information in the last 10 days before onset of diarrhea

Do you keep/rare or have contact with the following at home?

Yes No DK/NS

• Domestic pets ( e.g. dog, cat)

• Person (s) suffering from diarrhea in your household?

Are you on any long term medication or have you undergone surgery?

If yes, specify………………………………………………

• Have you/your child finished the childhood vaccines recommended by Kenya Expanded Immunization Program

7. Travel

Did you/your child travel outside the County

If yes (specify) Date ……….. Where …………………

• Fecal disposal Yes No

Do you have toilet facility if so

Do you use the toilet regularly?

8. Economic factors

‒ Type of house:

Permanent

Semi-permanent

Thatched with mud soil

‒ Type of lighting system in the house:

Electricity

Solar

Paraffin

‒ What do you use for cooking at home?

Firewood

Charcoal

Paraffin electricity

Gas

This is the end of the formal interview. Thank you very much for your time and cooperation.

Do you have any questions? _______________________________________

Thanks and Good bye.