Determinants of Hemolytic Uremic Syndrome in Children Under Five Years of Age in Argentina

Leila Vanela López; Jorge Eduardo Larcamon

doi:10.56294/shp2025224

Abstract

Introduction: hemolytic uremic syndrome (HUS), associated with Shiga toxin-producing Escherichia coli (STEC), is a leading cause of acute renal failure in children under five years of age. In Argentina, its high incidence reflects challenges in access to drinking water, food hygiene and health education. Objective: to evaluate the determinants of the incidence of HUS in Argentine children, focusing on hygiene practices, food consumption, access to water and knowledge of caregivers. Methods: observational and descriptive study with three phases: literature review, survey to 33 parents of children <5 years old (food habits, hygiene, knowledge of HUS) and comparative analysis with data from the National Epidemiological Bulletin. Results: 90,9 % of respondents resided in urban areas, with access to treated water (81,8 %) and high hygiene practices (84,8 % hand washing). However, risks persist: 48,5 % consume unpasteurized products, 33,3 % do not use separate cutting boards and 30,3 % do not know about HUS. The Bulletin highlights higher incidence in rural areas with poor infrastructure and in hot seasons. Cross-contamination and food handling in restaurants were factors highlighted. Conclusions: the incidence of HUS in Argentina is linked to gaps in the rigorous implementation of hygiene practices, unequal access to drinking water and lack of knowledge about prevention. Educational campaigns, improvement of sanitary infrastructure and food controls are recommended, especially in vulnerable areas and during periods of higher risk. The integration of public policies and community education could reduce the burden of the disease in the child population.

Keywords

Hemolytic-Uremic Syndrome, Argentina, Food Ingestion, Child

INTRODUCTION

Hemolytic Uremic Syndrome (HUS) is among the main causes of acute renal failure in childhood, especially in children under 5 years of age. This clinical syndrome is characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal damage, and in most cases it is associated with infection by Shiga toxin-producing Escherichia coli (STEC). Transmission of this bacterium occurs mainly through contaminated food —such as undercooked ground meat, unpasteurized dairy products, and raw vegetables— or by direct contact with infected people or animals, young children being a particularly vulnerable population due to their immature physiology and behavioral habits.(1,2)

In Argentina, SUH represents a serious public health problem. The disease is endemic and disproportionately affects the sectors most exposed to deficient sanitary conditions, such as lack of access to safe drinking water or inadequate food handling practices. Although the country has had mandatory reporting of SUH since 2000 and a National Prevention and Control Program since 2009, indicators continue to show a high incidence, especially in rural and peri-urban areas, and during warm seasons such as spring and summer.

The identification of risk factors is crucial for the implementation of more effective public health policies. Various studies have indicated that water quality, food hygiene practices, and the level of knowledge about SUH among caregivers are determining variables in the occurrence of new cases. In this context, it is essential to develop studies that integrate both official epidemiological data and first-hand information from families, in order to establish precise correlations and promote targeted preventive interventions.

The present study seeks to provide empirical evidence on the factors that influence the high prevalence of SUH in children under 5 years of age in Argentina. To this end, an observational and descriptive study is conducted based on one survey of parents of children in that age group, complemented by a comparative analysis with data from the Boletín Epidemiológico Nacional. This approach aims to shed light on everyday practices of consumption, hygiene, and access to water, as well as on the degree of knowledge held by responsible adults regarding this disease, with the purpose of contributing to the design of more effective prevention and health education strategies.

What are the determining factors of the high incidence of Hemolytic Uremic Syndrome in Argentina in children under 5 years of age, and how do hygiene practices, access to drinking water, and caregivers' knowledge about the disease influence this?

General objective

To evaluate the determining factors of the high incidence of Hemolytic Uremic Syndrome in children under five years old in Argentina, with emphasis on hygiene practices, food consumption, access to safe drinking water, and the level of knowledge of caregivers.

METHODS

Hemolytic uremic syndrome

SUH is a clinical syndrome that involves hemolytic anemia (with fragmented red blood cells), low blood platelet levels (thrombocytopenia), and acute kidney injury (LRA); the latter being the main infectious cause of LRA in children. The main reason for the appearance of SUH is the damage to endothelial cells in the microvasculature (arterioles, capillaries, and venules), although the etiology and pathogenesis vary.(3) Patients with SUH-STEC present with fatigue, pallor, dizziness, sometimes petechiae and hematomas, shortness of breath, edema, and decreased urine output, all suggestive of SUH-STEC due to the previous episode of bloody diarrhea.

The main virulence factor of STEC strains are the so-called Shiga toxins, encoded by the stx genes. The adhesin intimin, encoded by the eae gene, is involved in the intimate adherence of bacteria to enterocytes. The Stx gene is encoded in a lysogenic bacteriophage integrated into the bacterial DNA. Stx production depends on the replicative cycle of the Stx phage and its release after bacterial lysis.(5) However, STEC strains lacking this gene can also cause disease in humans. Although it has not yet been established which combination of markers defines whether an STEC strain is pathogenic, the presence of the stx/eae genes is associated with a risk of more severe disease.(4) There are two families of Stx toxins: Stx1 and Stx2, each of which in turn presents different variants. Although all variants have been isolated from patients with diarrhea, not all of them have the same degree of association with the development of the most severe clinical forms.(6,7,8,10,11)

In Argentina, as in the rest of the world, cattle are the natural and most important reservoir of E. coli O157:H7. STEC strains have been recovered from fecal samples in 39 % of healthy animals. STEC are transmitted to humans through food and water contaminated with the feces of carrier animals.(6) Other proposed transmission routes are associated with direct contact with carrier persons or animals, through the fecal-oral route. The sources of infection most frequently found associated with SUH in our country are: foods with insufficiently cooked ground meat, apple juices or unpasteurized dairy products, raw vegetables, salami, and blood sausage.(14)

The bacterium colonizes the intestine and begins to produce Shiga toxin (Stx), which enters the circulation and binds to its specific receptor present mainly in the renal glomerular endothelium and tubular epithelium, where it is internalized and causes cell death.(8)

**Figure 1.** Cellular Structure and Components

The incubation period usually ranges from 2 to 12 days, with an estimated median of 3 days, and may occasionally be longer. The predominant symptom is diarrhea, which is bloody in 60% of patients. Abdominal pain is more intense than in other bacterial gastroenteritides, and most patients infected with O157:H7 do not present with fever. Nausea and vomiting are sometimes reported. Diarrhea usually resolves within a week and is complicated by hemolytic uremic syndrome in approximately 15% of cases (5-10% of sporadic cases, >20% during outbreaks).(3,4,5,6,7,8,9,10,11)

Diagnosis

From a clinical standpoint, the diagnosis of STEC-HUS is mainly based on a possible history of previous infection or exposure, the corresponding clinical symptoms, and auxiliary examinations (7,8) indicating thrombotic microangiopathy, such as non-immune hemolytic anemia (hematocrit < 30%, with fragmented erythrocytes in the peripheral blood smear and a negative Coombs test), thrombocytopenia (platelet count < 150,000 mm3), and abnormal renal function (a serum creatinine concentration exceeding the upper limit of the reference range for age), with or without hypocomplementemia. If STEC-HUS is suspected, stool and serological tests are required to determine whether there is evidence of STEC infection (3,4,5,6,8,9,11).

Treatment

Treatment of STEC-HUS is mainly symptomatic. Patients require hospitalization in specialized services familiar with the management of renal injury and red blood cell transfusions, as well as the detection, monitoring, and treatment of hypertension, neurological manifestations, intestinal complications, pancreatitis, and ischemic cardiomyopathy. Careful management of intravascular volume is extremely important in the acute phase.(3,4,5,6,7,8,9,11)

Research objective

In the present work, the PICO format is used to formulate the research question: What are the determining factors of the high incidence of hemolytic uremic syndrome in children under 5 years of age in Argentina? Thus, this thesis aims to evaluate hygiene and food consumption practices in families with children in the aforementioned age range, analyze access to drinking water and disinfection practices in each household, and determine the level of parents' knowledge about SUH and its relationship with food hygiene.

Study Design and Methodology

This study has an observational and descriptive design; it seeks to identify risk factors associated with SUH in children under 5 years of age.

To carry out the present work, the PICO format is used to formulate the research question: What are the determining factors of the high incidence of hemolytic uremic syndrome in Argentina among children under 5 years of age?

The study is carried out in 3 phases.

Phase 1: Literature Review

A bibliographic review was conducted by analyzing databases such as Scielo, Elsevier, and PubMed; in the latter, MeSH (medical subject headings) terms were applied as search filters using the keywords “Hemolytic Uremic Syndrome; renal failure; epidemiology; STEC infection; prevention”, selecting the most relevant articles on the study of SUH, STEC, and the prevalence of this disease in Argentina. This allowed the selection of relevant articles to theoretically support the study, with emphasis on research linking SUH with environmental and sanitary factors in the pediatric population of Argentina.

Phase 2: Field Survey

In this phase, a field survey was designed as a multiple-choice, closed-ended questionnaire administered through the Google Forms platform (https://forms.gle/nUiLanrYhLzjemSL9). The survey was completed by 33 parents of children under 5 years of age and included questions about: demographic data (age, sex, area of residence); meat and dairy consumption habits, with emphasis on unpasteurized products; access to and treatment of water; knowledge about SUH and its relationship with water and food quality; and hygiene practices in the preparation and consumption of food, such as hand washing, disinfection of fruits and surfaces, and separate use of cutting boards.

The results were collected and organized in a database to calculate the percentages and frequencies of each response.

Phase 3: Comparative Analysis with the National Epidemiological Bulletin

The survey data are contrasted with information from the National Epidemiological Bulletin to identify similarities and differences in risk factors for HUS across different areas of Argentina. This analysis allows the identification of how risk factors related to water quality and dietary practices are geographically distributed in the country and how they affect the incidence of HUS in the vulnerable child population.

In this study, the incidence of risk factors associated with SUH in children under 5 years of age is used as a variable, considering the studied population.

Study limitations

Among the limitations, the small sample size is noteworthy; the results may not be completely representative of the general population.

Due to time constraints during the preparation of this work, the sample consists mainly of urban residents, which could bias the results.

Initially, a review of medical records at Hospital Gandulfo was planned, but this was not possible due to access restrictions, which limited the analysis to data obtained from the form and from public bulletins.

Inclusion and Exclusion Criteria

Table 1. Inclusion Criteria

Inclusion Criteria	Description
Age of the children	Children under 5 years
Participation in the questionnaire	Parents of children under 5 years of age who have completed the questionnaire on risk factors associated with SUH
Area of residence	Residents of Argentina

Table 2. Exclusion Criteria

Exclusion Criteria	Description
Age of children	Children over 5 years and children under 1 year
Residence outside Argentina	Children residing outside Argentina, since the study focuses on the child population of the country
Unrelated Medical Conditions	Children with chronic medical conditions not related to HUS, to avoid bias in the analysis

The inclusion and exclusion criteria were selected based on the results obtained from the form, considering the determining factors of SUH in Argentina.

RESULTS

33 parents of children under 5 years of age were surveyed, with the following results:

Demographic Profile: 54.5% of respondents are 5 years old, 60.6% are male, and 90.9% reside in urban areas.

Meat and Dairy Consumption: 63.6% consume beef several times a week, and 100% report that the cooking point is "well done". 48.5% report consuming unpasteurized products. Regarding fast food restaurants, although 48% report rarely attending, 63.3% report attending them.

Hygiene practices: 84.8% reported washing their hands before preparing food, and 90.9% disinfect fruits and vegetables before consumption. However, only 66.7% use separate cutting boards for meats and vegetables.

On the other hand, although 78.8% have knowledge about cross-contamination, 21.2% do not.

Water Quality and Treatment: 81.8% treat water before consumption, with the most consumed water types being bottled water (33.3%) and public network water (30.3%).

Knowledge about SUH: 60.6% of parents have knowledge about SUH, while 30.3% have no information about it but would like to be informed.

Water Quality and Treatment: 81.8% treat water before consumption, with the most consumed water types being bottled water (33.3%) and public network water (30.3%).

The National Epidemiological Bulletin reports that the incidence of HUS is higher in regions with lower access to treated drinking water, especially in rural areas. Although in the present study, the majority of respondents reside in urban areas and have access to treated water, a significant proportion still does not apply adequate hygiene measures, which is associated with a high risk of HUS.

Table 3. Prevalence and Knowledge of SUH in Pediatric Population

Table 1.

Variable	Description of the Responses	Percentage (%)
Child's Age	3 to 4 years, 5 years, 1 to 2 years	54.5% (5 years), 39.4% (3 to 4 years), 6.1% (1 to 2 years).
Child's Sex	Female, Male	60.6% Male, 39.4% Female.
Residential Area	Urban, Rural	90.9% Urban; the rest Rural.
Meat Cooking	Well done	100 %
Consumption of Unpasteurized Products	Yes, No	48.5% Yes, the rest No.
Fast Food Restaurant Attendance	Yes, No	63.3% Yes, the rest No.
Hand Washing Before Preparing Food	Always, Sometimes	Almost always
Disinfection of Fruits and Vegetables	Yes, No	Majority Yes
Use of Different Cutting Boards	Yes, No, I do not use tables.	66.7% Yes, 27.3% No, the rest do not use.
Knowledge of Cross-Contamination	Yes, No	78.8% Yes, 21.2% No.
Attendance at Daycare or Kindergarten	Yes, No	Majority Yes
Case Reports of SUH in the Institution	Yes, No, I do not know.	51.5% No, 48.5% do not know.
Episodes of Vomiting or Diarrhea in 6 Months	Yes, No	57.6% No, 42.4% Yes.
Hospitalization for Severe Infections	Yes, No	Majority: No
Care for E. coli infections	Yes, No	Majority: No
Familiarity with SUH	Yes, No	60.6% Yes, 39.4% No.
Perception of the Relationship between SUH and Water/Food Quality	Yes, No, Not sure	42.4% Yes, 45.5% Not sure, 12.1% No.

DISCUSSION

The high incidence of hemolytic uremic syndrome (HUS) in Argentina represents a considerable burden on the public health system, especially in children under 5 years of age. Data from the National Epidemiological Bulletin highlight that lack of access to safe drinking water combined with inadequate hygiene practices are critical risk factors. In this study, we observed that, although the majority of respondents have access to treated water and adequate hygiene practices, gaps persist in the rigorous implementation of these measures. An example of this is the low percentage of respondents who use separate cutting boards, which increases the risk of cross-contamination.

Considering that most respondents reside in urban areas, where access to information and hygiene resources is relatively greater, it is possible that these results underestimate the situation in rural areas. If this survey were applied at the national level, including areas with less access to health education and hygiene resources, it is likely that knowledge about practices such as the prevention of cross-contamination would be even more limited, which could reflect an elevated risk in those regions.

On the other hand, a high percentage of respondents reported consuming beef and unpasteurized dairy products, which is relevant for SUH in Argentina, since these products can be vehicles for the bacterium Escherichia coli (E. coli) that produces Shiga toxin (STEC). This microorganism, according to the epidemiological bulletin, is among the primary etiological agents of SUH in Argentina. Although 100% of respondents report consuming well-cooked meat, prior handling and the possibility of cross-contamination, especially in fast food restaurants, represent a latent risk. It is possible that these practices contribute to exposure to the pathogen.(1,2,3,4,5)

Regarding water quality, most respondents report treating water before consumption; however, a small percentage does not, which increases vulnerability to infections that favor the development of HUS. This is especially relevant in Argentina, where there are areas with limitations in access to quality network water. According to the epidemiological bulletin, the incidence of HUS has been particularly high in areas where access to safe drinking water is limited or where water treatment infrastructure is not optimal. This suggests that public health policies should prioritize improving infrastructure for access to safe drinking water and sanitation, especially in rural and peri-urban areas.

On the other hand, the survey reveals that a large percentage of families consume bottled water, which suggests that access to and choice of water type are related to geographic and economic levels.(1,2,10,11)

Safe food handling is crucial for the prevention of SUH. Although the figures obtained from the form report high rates of hand hygiene and disinfection of food, utensils, and surfaces, it is notable that a percentage of the population does not always follow these practices. This proportion may be sufficient to increase the risk of cross-contamination, especially in the handling of raw meats, since 33.3% of people do not use separate cutting boards. This practice is key to the prevention of STEC transmission, both in the domestic environment and in restaurants. Therefore, it is important to implement educational campaigns aimed at the prevention of cross-contamination at home and in restaurants or food trucks.

Another aspect to consider is the high incidence of visits to fast food restaurants, since there is greater exposure to the risks described above.

Although 60.6% report having information about HUS, 30.3% do not have information about it but would like to have it. This incomplete knowledge of risk factors and preventive practices can negatively influence decision-making regarding eating habits and hygiene. The epidemiological bulletin reinforces the importance of health education, indicating that the lack of information in specific communities increases children's vulnerability to this disease (1,2,8,9,10). In conclusion, it is crucial to develop awareness campaigns in schools, daycare centers, and community centers, as they could be fundamental in reducing the risk in this vulnerable population group.

A notable finding is that 54.5% of parents have monthly incomes above 600,000 pesos, and approximately 66.7% of the communities have reached tertiary or university education. These levels may allow access to safe food or good-quality water, and the current educational level favors adequate hygiene practices. However, the presence of SUH in communities with better socioeconomic levels indicates that, even though socioeconomic level can reduce some risks, it does not eliminate exposure. This highlights the need to reinforce educational programs at all socioeconomic levels and to combat cross-contamination through rigorous hygiene practices when handling food (1,2,3,11).

The geographic distribution of SUH in Argentina shows higher prevalences in children under 5 years of age. Among the provinces of the Central regions (even more notable in jurisdictions such as CBA, SFE, MDZ, among others), the highest numbers of cases notified to health institutions are observed. Seasonality is a factor that warrants attention, since there are peaks in cases during summer and spring, which are associated with increased outdoor activities and the consumption of more perishable foods that could lead to greater exposure to the risk of contamination. Comparison with the data recorded in the questionnaire indicates that children in urban environments, although they have better access to health services and food products, are not exempt from risks due to the behavioral component of the children's caregivers (1,2,10,11). Therefore, it is advisable to intensify prevention measures during these seasons.

The bulletin emphasizes that the lack of education on preventive practices and deficient sanitation infrastructure are crucial factors contributing to the high incidence of SUH. This study reveals that, although many respondents are aware of the relationship between SUH and hygiene, there are still gaps in the implementation of these practices at home and in food establishments. The bulletin also provides data on the relationship between seasonality and the increase in SUH cases during hot seasons, probably due to increased consumption of perishable foods and outdoor activities. This suggests that prevention campaigns should be intensified during these critical periods.

Comparison of these data with reports from the Epidemiological Bulletin suggests that the predominant risk factors are linked not only to health infrastructure, but also to education and consumption practices. This underscores the relevance of implementing intervention strategies aimed at improving hygiene practices and access to drinking water.

In accordance with the bulletin, it is recommended that public health policies focus on the following: Continuing education programs: include health education modules on HUS, as well as hygiene practices in school programs.

Improvement in drinking water infrastructure: strengthen access to treated water in rural and peri-urban areas to reduce vulnerability to infections.

Strengthening sanitary controls: implement more rigorous controls in the handling and sale of food, whether in tanneries, sausage factories, dairy product factories, fast food establishments, among others.

Promotion of safe food preparation practices: promote the use of separate utensils for raw foods and strict hygiene in food handling.

Promotion of food handling practices: promote the care of the food cold chain, ensuring that foods are maintained under optimal storage conditions to prevent bacterial proliferation.

Attention during high season: prioritize food prevention and control campaigns during the highest-risk season (spring-summer).

CONCLUSIONS

In conclusion, the research highlights that the incidence of SUH in Argentina depends not only on infrastructure factors but also on hygiene and consumption practices that can be improved through education and health regulation. These strategies, combined, could significantly reduce the risk of SUH in the most vulnerable pediatric population, children under 5 years of age, contributing to the improvement of public health in the country.

References

1 Kliegman RM, Blum NJ, Shah SS, St Geme JW III, Tasker RC, Wilson KM. Nelson Tratado de Pediatría. 21.ª ed. Elsevier; 2020.
2 Fernández G, Amelotti L, Nicolau V, Vallone A, Altschuler A, Buoro E, et al. Informe Encefalitis Equina del Oeste. Boletín Epidemiológico Nacional. 2024;702.
3 Liu Y, Thaker H, Wang C, Xu Z, Dong M. Diagnosis and treatment for Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome. Toxins. 2022 Jan 1;15:10.
4 Fakhouri F, Schwotzer N, Frémeaux-Bacchi V. How I diagnose and treat atypical hemolytic uremic syndrome. Blood. 2023 Mar 2;141:984–95.
5 Oderiz S, Leotta GA, Galli L. Detección y caracterización de Escherichia coli productor de toxina Shiga en niños atendidos en un hospital pediátrico interzonal de la ciudad de La Plata. Rev Argent Microbiol. 2018;50:341–50.
6 Boyer O, Niaudet P. Hemolytic uremic syndrome: new developments in pathogenesis and treatment. Int J Nephrol. 2011;2011:908320.
7 Eymann A, Coccia P, Raddavero C, Lafi G, Ferraris V, Ramírez J, et al. Prevalence and clinical course of typical hemolytic uremic syndrome among siblings. Arch Argent Pediatr. 2016 Dec;114:549–56.
8 Belardo M. Epidemiological surveillance: caught up in the instrumental logic. The case of Hemolytic Uremic Syndrome in Argentina. Buenos Aires; 2013 Mar.
9 Ministerio de Salud de la Nación. Programa Nacional de Prevención del Síndrome Urémico Hemolítico. Buenos Aires: Ministerio de Salud.
10 Ylinen E, Salmenlinna S, Halkilahti J, Jahnukainen T, Korhonen L, Virkkala T, et al. Hemolytic uremic syndrome caused by Shiga toxin-producing Escherichia coli in children: incidence, risk factors, and clinical outcome. Pediatr Nephrol. 2020;35:1749–59.
11 Ministerio de Salud de la Nación. Campaña Nacional de Prevención del Síndrome Urémico Hemolítico: Importancia, Prevención y Seguimiento. Buenos Aires: Ministerio de Salud.
12 Eymann A, Coccia P, Raddavero C, Lafi G, Ferraris V, Ramírez J, et al. Prevalencia y evolución clínica del síndrome urémico hemolítico típico entre hermanos. Arch Argent Pediatr. 2016 Dec;114:553–6.
13 Fernandez-Brando RJ, Bentancor LV, Mejías MP, Panek AC, Cabrera GG, Exeni RA, et al. Escherichia coli productor de toxina Shiga. Medicina. 2011;71:383–9.

Declarations

Funding

Los autores no recibieron financiación para el desarrollo de la presente investigación.

Conflict of interest

Los autores declaran que no existe conflicto de intereses.

Authorship contributions

Conceptualization: Leila Vanela López, Jorge Eduardo Larcamon.

Data curation: Leila Vanela López, Jorge Eduardo Larcamon.

Formal analysis: Leila Vanela López, Jorge Eduardo Larcamon.

Writing – original draft: Leila Vanela López, Jorge Eduardo Larcamon.

Writing – review and editing: Leila Vanela López, Jorge Eduardo Larcamon.

[ref1] 1 Kliegman RM, Blum NJ, Shah SS, St Geme JW III, Tasker RC, Wilson KM. Nelson Tratado de Pediatría. 21.ª ed. Elsevier; 2020.

[ref2] 2 Fernández G, Amelotti L, Nicolau V, Vallone A, Altschuler A, Buoro E, et al. Informe Encefalitis Equina del Oeste. Boletín Epidemiológico Nacional. 2024;702.

[ref3] 3 Liu Y, Thaker H, Wang C, Xu Z, Dong M. Diagnosis and treatment for Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome. Toxins. 2022 Jan 1;15:10.

[ref4] 4 Fakhouri F, Schwotzer N, Frémeaux-Bacchi V. How I diagnose and treat atypical hemolytic uremic syndrome. Blood. 2023 Mar 2;141:984–95.

[ref5] 5 Oderiz S, Leotta GA, Galli L. Detección y caracterización de Escherichia coli productor de toxina Shiga en niños atendidos en un hospital pediátrico interzonal de la ciudad de La Plata. Rev Argent Microbiol. 2018;50:341–50.

[ref6] 6 Boyer O, Niaudet P. Hemolytic uremic syndrome: new developments in pathogenesis and treatment. Int J Nephrol. 2011;2011:908320.

[ref7] 7 Eymann A, Coccia P, Raddavero C, Lafi G, Ferraris V, Ramírez J, et al. Prevalence and clinical course of typical hemolytic uremic syndrome among siblings. Arch Argent Pediatr. 2016 Dec;114:549–56.

[ref8] 8 Belardo M. Epidemiological surveillance: caught up in the instrumental logic. The case of Hemolytic Uremic Syndrome in Argentina. Buenos Aires; 2013 Mar.

[ref9] 9 Ministerio de Salud de la Nación. Programa Nacional de Prevención del Síndrome Urémico Hemolítico. Buenos Aires: Ministerio de Salud.

[ref10] 10 Ylinen E, Salmenlinna S, Halkilahti J, Jahnukainen T, Korhonen L, Virkkala T, et al. Hemolytic uremic syndrome caused by Shiga toxin-producing Escherichia coli in children: incidence, risk factors, and clinical outcome. Pediatr Nephrol. 2020;35:1749–59.

[ref11] 11 Ministerio de Salud de la Nación. Campaña Nacional de Prevención del Síndrome Urémico Hemolítico: Importancia, Prevención y Seguimiento. Buenos Aires: Ministerio de Salud.

[ref12] 12 Eymann A, Coccia P, Raddavero C, Lafi G, Ferraris V, Ramírez J, et al. Prevalencia y evolución clínica del síndrome urémico hemolítico típico entre hermanos. Arch Argent Pediatr. 2016 Dec;114:553–6.

[ref13] 13 Fernandez-Brando RJ, Bentancor LV, Mejías MP, Panek AC, Cabrera GG, Exeni RA, et al. Escherichia coli productor de toxina Shiga. Medicina. 2011;71:383–9.