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.2016 Jun 27;5(1):64.
doi: 10.1186/s40249-016-0157-2.

Impact of co-infections with enteric pathogens on children suffering from acute diarrhea in southwest China

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Impact of co-infections with enteric pathogens on children suffering from acute diarrhea in southwest China

Shun-Xian Zhang et al. Infect Dis Poverty..

Abstract

Background: Acute diarrhea is a global health problem, resulting in high morbidity and mortality in children. It has been suggested that enteric pathogen co-infections play an important role in gastroenteritis, but most research efforts have only focused on a small range of species belonging to a few pathogen groups. This study aimed to assess the impact of co-infections with a broad range of enteric pathogens on children aged below five years who suffer from acute diarrhea in southwest China.

Method: A total of 1020 subjects (850 diarrhea cases and 170 healthy controls) were selected from four sentinel hospitals in Kunming, Yunnan province, southwest China, from June 2014 to July 2015. Stool specimens were collected to detect five virus (rotavirus group A, RVA; norovirus, NoV; Sapovirus, SaV; astrovirus, As; and adenovirus, Ad), seven bacterial (diarrheagenic Escherichia coli, DEC; non-typhoidal Salmonella, NTS; Shigella spp.; Vibrio cholera; Vibrio parahaemolyticus; Aeromonas spp.; and Plesiomonas spp.), and three protozoan (Cryptosporidium spp., Giardia lamblia, and Blastocystis hominis, B. hominis) species using standard microbiologic and molecular methods. Data were analyzed using the partial least square regression technique and chi-square test.

Results: At least one enteric pathogen was detected in 46.7 % (n = 397) of acute gastroenteritis cases and 13.5 % (n = 23) of healthy controls (χ(2) = 64.4, P < 0.05). Single infection with RVA was associated with acute diarrhea (26.5 % vs. 5.8 %, P < 0.05). The prevalence of a single infection with B. hominis in diarrhea cases was higher than in healthy controls (3.1 % vs. 0.5 %, OR = 4.7, 95 % CI: 1.01-112.0). Single infection with NoV GII was not associated with diarrhea (4.4 % vs. 3.5 %, OR = 1.2, 95 % CI: 0.5-3.3). Single infections with bacterial species were not observed. The prevalence of co-infections with two enteric pathogens in diarrhea cases was higher than in asymptomatic children (20.1 % vs. 5.3 %, P < 0.05). RVA-NoV GII was the most common co-infection in symptomatic children (4.4 %), with it aggravating the severity of diarrhea.

Conclusions: Although it is clear that RVA has an overwhelming impact on diarrhea illnesses in children, co-infection with other enteric pathogens appears to also aggravate diarrhea severity. These findings should serve as evidence for public health services when planning and developing intervention programs.

Keywords: Bacteria; Children; China; Co-infection; Diarrhea; Intestinal protozoa; Kunming; Severity; Virus; Yunnan.

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Figures

Fig. 1
Fig. 1
Bubble chart showing the relationship between PLS X’s component, representing the enteric pathogen community, and the severity of diarrhea (MNLS per 24 h) in 850 children aged below five years in Kunming, southwest China. In the PLS X’s component, virus richness, RVA (here shown as rotavirus), and NoV GII (shown as norovirus) were the most important variables of enteric pathogen PLS X’s component. On the other hand, diarrhea severity (response variable) was represented by the MNLS per 24 h. The initial set of variables representing the X’s component can be seen in Table 3. Bubble size indicates virus richness that ranged from 0 (virus free) to three virus types (children co-infected with RVA, Ad, and NoV). Bubble color, however, indicates a specific co-infection. The horizontal grey dotted line shows the 90th percentile
Fig. 2
Fig. 2
Heatmap showing associations between significant enteric pathogen species determined using the probabilistic co-occurrence model for enteric pathogens detected in 850 children (<5 years) suffering from acute diarrhea in Kunming, southwest China. The column and row represent pairwise relationship among two enteric pathogens. Boxes in grey color indicate random co-occurrences, orange boxes indicates associations were less common than expected by chance
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