Tropheryma whipplei associated with diarrhoea in young children
Authors: G Noël
V Brémond
S Benkouiten
J-C Lagier
R Laporte
J Gaudart
J-L Jouve
D Raoult
P Minodier
A Boutin
F Fenollar
H Richet
S Miramont
Journal: Clinical Microbiology and Infection (2016)
Discipline: IMMUNOLOGY
Keywords: Clostridium difficile; Diarrhoea; Gastroenteritis; Giardia duodenalis; Tropheryma whipplei
Affiliations: Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, UM63, CRNS7278, IRD198, InsermU1095, Institut Hospitalo-Universitaire Méditerranée-Infection, Aix-Marseille Université, Marseille, France., Paediatric Emergency Unit, Hôpital Nord, Marseille, France., Paediatric Emergency Unit, Hôpital Timone, Marseille, France., Aix-Marseille University, UMR912 SESSTIM (INSERM-IRD-AMU), Marseille, France., Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, UM63, CRNS7278, IRD198, InsermU1095, Institut Hospitalo-Universitaire Méditerranée-Infection, Aix-Marseille Université, Marseille, France. Electronic address: .

Abstract:  Tropheryma whipplei was detected in preliminary studies in faeces of young children with diarrhoea and also in faeces of asymptomatic persons, not only in Europe but also in Africa. In this study, the link between this bacterium and the presence of acute diarrhoea was evaluated in a large group of children. From December 2009 to January 2013, rectal swabs collected from 3796 children in the emergency departments of university hospitals in Marseille, France, were analysed: 555 children (245 female and 310 male, from 6 days to 6 years old) with acute diarrhoea defined as at least three loose stools per day for &lt;1 week and 3241 children (1444 female and 1797 male, from 22 days to 6 years old) without diarrhoea. Specific quantitative real-time PCR was performed to detect the presence of T. whipplei and of two enteric pathogens Clostridium difficile and Giardia duodenalis. Tropheryma whipplei was significantly more common in children with diarrhoea (22/555, 4%) than without (56/3241, 1.7%; p 0.001). Neither C. difficile nor G. duodenalis showed this association. For C. difficile, 39 of 531 (7.3%) children with diarrhoea were positive versus 184 of 3119 (5.9%) of children without diarrhoea (p 0.25). For G. duodenalis, 2 of 529 (0.37%) children with diarrhoea were positive versus 5 of 3119 (0.16%) children without diarrhoea (p 0.26). Tropheryma whipplei was found more commonly in autumn. Tropheryma whipplei is significantly associated with diarrhoea in children, suggesting that the bacterium may be a cause of acute diarrhoea. 

Retracted: No

PubPeer comments:
 This paper is part of a set of 2 papers with the ethical approval number 13u2013028. Some of the authors have participated to both articles. **[ARTICLE 1 -TROPHERYMA WHIPPLEI ASSOCIATED WITH DIARRHOEA IN YOUNG CHILDREN] 30229-4 fulltext#supplementaryMaterial)** **Preliminary note:** The paper was submitted in May 2016, revised in June and accepted in July 2016. We can note that the main investigator of the study is one of the author (see below the picture 2). According to the [letter of the New Editor in Chief] 00953-2 fulltext), *in 2008, the team from Marseille assumed the editorial functions for Clinical Microbiology and Infection (CMI)*. Between 2008 and April 2016, the investigator of the study, also author of this paper, was the Editor in chief of the Journal (see [Message from the new CMI Editor-in-Chief] 30013-1 abstract). The investigator of this study remains in the [guest Editors of the Journal] 00953-2 fulltext) in 2016. It should be noted that the new Editor in Chief re-affirms the willing of the Journal to follow the Helsinki Declaration. Indeed, in August 2016, an [ethical policy] 30317-2 fulltext) signed by the new Editor in Chief emphasis the need of a ethics approval before the start of the recruitment for prospective interventional or observational study: *We cannot accept any study describing an intervention in humans without the approval of a Research Ethics Committee, obtained before the study s start. (...)* *(...)We have encountered studies in which a new laboratory test was performed in real time in a research project, without submitting the study protocol to the Research Ethics Committee. This is inadmissible, because of a possible infringement on the autonomy of the patient, and also because a question about patient safety might arise. Studies in which a new laboratory test is performed in real time, and the result linked to a patient s data, should be approved by the Research Ethics Committee. Prospective observational studies (in which the data collection and follow up are structured and more stringent than clinical practice) should also be submitted for the approval of the Research Ethics Committee.* **This paper describes a prospective study** In the acknowledgement, the paper mention that: *This study was supported by the Cru00e9dit Ministu00e9riel u2018Programme Hospitalier de Recherche Cliniqueu2019 2009*. The reader can understand that this study has been planned before or in 2009 and the recruitment can be considered as prospective. This is also in line with the [APHM s Newsletter - March 2010](http: fr.ap-hm.fr sites default files files Recherche ECHO_1_vs3.pdf) and the [Health Minister communication] which present the winners of the call for tender Programme Hospitalier de Recherche Cliniqueu2019 2009. The newsletter also presents the main purpose of this prospective study (translated from french): *The aim of this project is to research T. whipplei by amplification gene in the stools and saliva of all children under the age of 5 years, presenting to the emergency room with a gastroenteritis but also in those presenting for another reason than a digestive table. This study will confirm and determine with accuracy the prevalence of T. whipplei as an agent of gastroenteritis in young children but also to seek the existence of healthy carriers.* **Picture 1 - APHM Newsletter** ![file] **Picture 2 - Health Minister communication** ![file] Based on these elements, the reader can consider this is a prospective study in human. **Prospective recruitment between 2009 and 2013** The paper mentions that children has been recruited *from December 2009 through January 2013*. Considering the 2009 call for tender to fund this research, it reinforces the fact that it was a prospective recruitment between 2009 and 2013. **Helsinki Declaration and Retrospective ethics approval** According to article 23 of the Helsinki Declaration, *the research protocol must be submitted for consideration, comment, guidance and approval to the concerned research ethics committee before the study begins. When it is not the case, article 36 provide that *reports of research not in accordance with the principles of this Declaration should not be accepted for publication*. According to Editor s Policy and the Guide for Authors, *if the work involves the use of human participants, the author should ensure that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans*. With regards to the information stated above, a retrospective ethics approval can not be considered for peer review. **Did the authors obtain the ethics approval retrospectively, after the beginning of the recruitment of children?** The authors mention that * all aspects of the study were approved by the local ethics committee (agreement no. 13-028) *. This is very surprising. Indeed, according to the institution habits, the first number is related to the year of the request has been made and or has been approved. If the local ethics committee received or approved the study in 2013, it should be considered as a retrospective ethics approval. In this case, can the Editor explain the reason of the acceptance of the peer review considering the Editor s Policy and the provision of the Helsinki Declaration mentioned above. **Did the author obtain an approval from a Comitu00e9 de Protection des Personnes (CPP)?** Usually, in France, study in human requires an approval from a CPP (Certified IRB) before to start the recruitment. Between 2006 and 2010, [the French Health Code] required to get a CPP approval before the recruitment of participants for observational prospective study in humans with minor interventions. This study seems to be cover by this situation. However, there is no mention about a CPP approval in the paper. Could the authors clarify if a CPP approval has been obtained. In this case, could the authors provide the approval number and the date of approval? **Primary and secondary endpoints** The paper only describes the results on rectal swab and don t detail the result on saliva. According to the newsletter and Health Minister communication, it can be guessed that the primary endpoint was to evaluate the presence of T. whipplei in the stools. But authors also mention that they have also evaluated the presence of 2 others micro-organisms (Giardia duodenalis and Clostridium difficile). The authors didn t mention if these other researches are part of the primary endpoint or part of the secondary or exploratory endpoints. The public will gain more clarity by having these specifications. **[ARTICLE 2 - COMMON SUBCLINICAL HYPOTHYROIDISM DURING WHIPPLE s DISEASE] ** The paper was submitted and published in 2014, before the publication of article 1. Article 1 and 2 use the same approval number (13--028): - Article 1 describes a prospective study in children only, recruited between 2009 and 2013. - Article 2 describes a retrospective study in adults only, recruited between 2001 and 2012. **How the ethical approval number used for a prospective study recruiting children between 2009 and 2013 can be also use for a retrospective study in adults only ?** Adults have been recruited year before, between 2001 and 2012. Data collected don t come from rectal swab. They come from serum. And the primary outcome is totally different (hypothyroidism during Whippleu2019s disease) Could the authors clarify how the same ethical approval number can be used in 2 different studies, one prospective and the other retrospective, with 2 different populations and with 2 different objectives? , 
 In the letter to Editors  [Tropheryma whipplei prevalence strongly suggests human transmission in homeless shelters] 01186-1 fulltext) , same of the authors mention: * The study was approved by the local ethics committee of IFR 48 (Marseille, France) in January 2010 (No. 10-005) and January 2011 (No. 11-004) *. It seems to be the same ethics committee with the same ethical approval number format. We can see that - the number 10 in the approval Nu00b0 10-005 is related to the approval Year 2010. - the number 11 in the approval No. 11-004 is related to the approval Year 2011. In accordance with this format, used by the ethics committee of this institution, it could be assumed with a good confidence that the ethics approval number 13-028 in the 2 articles described in comment #1 has been obtained in 2013. , 
 According to this [Mediapart s article] , the French Medicines Agency (ANSM) performed a GCP inspection in November 2021 (GCP = Good Clinical Practices). This inspection covers the 2 articles mentioned by #1 (including this article). In the preliminary report, the French Medicines Agency mentioned that: - this study in young children (including one minor) was a research in humans. - this study was not approved by a Comitu00e9 de Protection des Personnes (CPP), which is mandatory in France for the research in humans. Approval must be obtained before the first recruitment. - 30 consent forms were not signed by parents of the minors (or their legal representatives) Based on this article, comment from #1 seems to be accurate. ,