A systematic review of ETEC epidemiology focusing on colonization factor and toxin expression

S. D. Isidean, M. S. Riddle, S. J. Savarino, C. K. Porter*

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

196 Scopus citations


Introduction: Vaccine development for enterotoxigenic Escherichia coli (ETEC) is dependent on in-depth understanding of toxin and colonization factor (CF) distribution. We sought to describe ETEC epidemiology across regions and populations, focusing on CF and toxin prevalence. Methods: We conducted a systematic review of the published literature, including studies reporting data on ETEC CF and toxin distributions among those with ETEC infection. Point estimates and confidence intervals were calculated using random effects models. Results: Data on 17,205 ETEC isolates were abstracted from 136 included studies. Approximately half of the studies (49%) involved endemic populations, and an additional 17% involved only travel populations. Globally, 60% of isolates expressed LT either alone (27%) or in combination with ST (33%). CFA/I-expressing strains were common in all regions (17%), as were ETEC expressing CFA/II (9%) and IV (18%). Marked variation in toxins and CFs across regions and populations was observed. Discussion/conclusions: These results demonstrate the relative importance of specific CFs in achieving target product profiles for a future ETEC vaccine. However, heterogeneity across time, population, and region, confounded by variability in CF and toxin detection methodologies, obfuscates rational estimates for valency requirements.

Original languageEnglish
Pages (from-to)6167-6178
Number of pages12
Issue number37
StatePublished - 26 Aug 2011
Externally publishedYes


  • Colonization factor
  • ETEC
  • Enterotoxigenic Escherichia coli
  • Heat-labile toxin
  • Heat-stable toxin


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