Multiple etiologies of infectious diarrhea and concurrent infections in a pediatric outpatient-based screening study in Odisha, India
© The Author(s) 2017
Received: 7 August 2016
Accepted: 27 March 2017
Published: 11 April 2017
There are multiple etiologies responsible for infectious gastroenteritis causing acute diarrhea which are often under diagnosed. Also acute diarrhea is one of the major causes of morbidity and mortality among children less than 5 years of age.
In our study, fecal samples (n = 130) were collected from children (<5 years) presenting with symptoms of acute diarrhea. Samples were screened for viral, bacterial, and parasitic etiologies. Rotavirus and Adenovirus were screened by immunochromatographic tests. Diarrheagenic Escherichia coli (EPEC, EHEC, STEC, EAEC, O157, O111), Shigella spp., Salmonella spp., Vibrio cholera, Cryptosporidium spp., and Giardia spp. were detected by gene-specific polymerase chain reaction.
Escherichia coli was detected to be the major etiological agent (30.07%) followed by Rotavirus (26.15%), Shigella (23.84%), Adenovirus (4.61%), Cryptosporidium (3.07%), and Giardia (0.77%). Concurrent infections with two or more pathogens were observed in 44 of 130 (33.84%) cases with a predominant incidence particularly in <2-year-old children (65.90%) compared to children of 2–5 years age group (34.09%). An overall result showed significantly higher detection rates among children with diarrhea in both combinations of two as well as three infections concurrently (p = 0.004915 and 0.03917, respectively).
Suspecting possible multiple infectious etiologies and diagnosis of the right causative agent(s) can aid in a better pharmacological management of acute childhood diarrhea. It is hypothesized that in cases with concurrent infections the etiological agents might be complementing each other’s strategies of pathogenesis resulting in severe diarrhea that could be studied better in experimental infections.
KeywordsDiarrhea Infectious diarrhea Children Concurrent infection Co-infection Odisha
Global and national estimates clearly indicate that diarrheal disease is a major public health concern [1, 2]. According to the World Health Organization (WHO), diarrheal diseases are the second leading cause of death (~760,000 per year) in children <5 years of age. Recent studies suggested that diarrheal diseases are the leading cause of childhood deaths in developing countries. Infectious agents, viz., viruses (Rotavirus, Adenovirus, Hepatitis A&E, Norwalk), bacteria (E. coli, Salmonella, Shigella, Vibrio), protozoa (Giardia, Cryptosporidium, Cyclospora, Microsporidia, Isospora), etc., are usually responsible for serious diarrheal disease outbreaks [3–5]. Among these pathogens, diarrheagenic E. coli (DEC), Rotavirus, and Shigella spp. are the major contributors of childhood morbidity and mortality [6–8].
Globally Rotavirus is responsible for around 0.5 million-child deaths annually , while national estimates from India showed that Rotavirus is responsible for almost 0.1 million deaths, 0.4–0.8 million hospitalization, and 2 million outpatient visits in children <5 years of age . Among DECs, enteropathogenic E. coli (EPEC) strain accounts for 5–10% of pediatric diarrhea in resource-poor countries . Shigellosis, caused by enteroinvasive E. coli or Shigella spp., plays an important role in morbidity and mortality among children <5 years of age. About 125 million cases of endemic shigellosis occur every year in Asian countries [12, 13].
Also past studies from developing countries suggest Cryptosporidium to be the leading cause of parasitic diarrhea among children [3, 14], while Giardia infects 200 million people each year in developing countries such as Africa, Asia and Latin America . Various studies have elucidated the prevalence of different etiological agents in children with diarrhea [16–18].
Poor hygiene and sanitation condition increases the transmission dynamics of diarrheal diseases in community settings. All these diarrheal agents are transmitted either through contaminated food, water, or through the fecal oral route. However, there are limited numbers of studies focusing on multiple etiologies particularly in children with diarrhea [19, 20].
Concurrent infection with more than single pathogen might be common among children with diarrhea. Also multiple infections of diarrheal pathogens might cause more severe diarrhea compared to infection with a single pathogen, thereby complicating the treatment management procedures [17, 21]. Due to scarcity of reports on concurrent infections causing diarrhea among children from the studied province in India, we attempted to estimate the overall burden of major diarrheal pathogens and possible concurrent infections with multiple infectious agents among children in a hospital-based screening study.
This study was conducted in a tertiary care teaching hospital in Bhubaneswar, Odisha (India). Fecal samples were collected from 130 children from June 2015 to April 2016. Stool samples were collected from children considering the inclusion and exclusion criteria. Inclusion criteria were children less than 5 years of age and 3 or more than 3 diarrheal episodes in a day. Children having malabsorption, immunocompromised individuals, and patients who have undergone immune suppressive therapy and prolonged steroid treatment were excluded from our study. Fecal samples were also collected from 48 non-diarrheal children less than 5 years of age, which acted as a control group. The study protocol was reviewed and approved by the Institutional Ethics Committee. Informed consent and patient datasheets were maintained for each participant.
Sample collection and DNA extraction
From each of these participants, fecal samples were collected in a sterile vial. Samples were placed on ice and transported to lab within 4 h and processed immediately. Total fecal genomic DNA was extracted from stool using QIAamp Fast DNA stool Mini Kit (Qiagen, Germany) according to the manufacturer’s instruction. The quantity and purity of extracted DNA were measured using a Nanodrop (Epoch BioTek, USA).
Extracted DNA samples were stored at −20 °C until further processing. Bacterial genomic DNA was isolated from pure cultures of S. enterica subsp., serovar typhimurium, V. cholera, S. flexneri, and E. coli (from the repository) using blood and tissue genomic DNA isolation kit (Qiagen, Germany) as per the manufacturer’s protocol. These were used as positive controls for pathogen detection by polymerase chain reaction (PCR).
Immunochromatographic test for detecting viral pathogen
Fecal specimens were screened for the presence of Rotavirus and Adenovirus by using immunochromatographic test (Combi-Strip C-1004, Coris Bioconcept ltd- Belgium) in accordance with the manufacturer’s instructions. This is a rapid diagnostic test based on homogenous membrane system with colloidal gold particles. The test was carried out as described previously .
PCR assay for detecting bacterial and parasitic pathogens
Detailed description of pathogen-specific polymerase chain reaction primers for their specific detection in stool
Primer sequence (5′ to 3′)
EPEC eae gene
EHEC hlyA gene
O111 rfb region
CAG CGT CTT TCA GCG ACA GTG TTT
AGC ATG ATA CTC AAC AGC CAG ACC
ATA CTG GCT CCT GTC ATT CAC GGT
GGA AGT GAC AGG GCA TTT GTG GAT
TGT GTT TTA TCT GAT GCA AGA GG
TGA ACT ACG TTC GTT CTT CTG G
18 s SSU rRNA locus
18 s Morgan F
18 s Morgan R
To examine associations between the presence or absence of diarrheal pathogen and risk factors within the different age groups (<2 or ≥2 years) and different multiple infections in children, logistic regression was used. Residence location (rural or urban) was considered for their possible association with the occurrence of diarrheal pathogen infections. Descriptive statistics was done to calculate odds ratios and 95% confidence intervals (CI), and p values were used to infer statistical associations based on one-tailed t test (Mantel–Haenszel Chi-square statistics) using free statistical software Epi-Info (http://www.openepi.com).
Frequencies of detection of etiological agents causing diarrhea in children
Infectious agent detected
Method of detection
Frequency (%) of detection in
Diarrheal group (n = 130)
Non-diarrheal group (n = 48)
Among the control subjects for which DEC was detected, the majority had infections with EPEC (10.41%) followed by STEC (6.25%), EAEC (2.08%), and O 157 (2.08%). No healthy subject was detected with Rotavirus, Giardia, Cryptosporidium spp., Salmonella spp., and Vibrio spp. The pathogen detection rates for cases and controls for each pathogen category are statistically analyzed which showed a significantly higher detection rate for Shigella spp (p = 0.0086) and Rotavirus (p = 0.0135), whereas the differences were not significant for rest of the detected pathogens.
Gender-wise distribution of incidences of infectious etiologies of diarrhea in children
Total no of samples
Total no. with an infectious diagnosis
No (%) of cases tested positive for different etiologies
95% CI (lower, upper)
Location-wise distribution of incidences of infectious etiologies of diarrhea
Total no of samples
Total no. with an infectious diagnosis
No (%) of cases tested positive for different etiologies
95% CI (lower, upper)
Age group-wise distribution of incidences of different etiological agents causing diarrhea in children in diarrheal group
No (%) of cases under age groups
<2 years (n = 82)
2–5 years (n = 48)
Odds ratio (95% CI)
At least one infectious etiology
1.195 (0.582, 2.449)
0.611 (0.285, 1.309)
1.085 (0.468, 2.515)
3.63 (1.377, 9.57)
0.275 (0.048, 1.562)
Age group-wise distribution of incidences of different strains of Diarrheagenic E. coli causing diarrhea in children
No (%) of cases under age groups
<2 years (n = 22)
2–5 years (n = 18)
Odds ratio (95% CI)
Co-infection combinations with two or more infectious etiologies detected in diarrheagenic group vs controls
Combinations of pathogens
Frequency (%) of detection cases (n = 130)
Frequency (%) of detection controls (n = 48)
Two-tailed p value by Mantel–Haenszel Chi-square test = 0.004915*
Double infection (total)
Two-tailed p value by Mid-P exact test = 0.03917*
Triple infection (total)
Two-tailed p value by Mid-P exact test = 0.7303
Combination of Pathogens (more than three infections)
An overall analysis showed statistically significant differences between detection rates for combinations of two infections concurrently among cases vs controls (p = 0.004915). Co-infection of Rotavirus with Shigella was the most frequent combination, which was detected in 5.38% cases, followed by Rotavirus with EPEC (4.61%) and Shigella with STEC (3.84%). Co-infections with detection of two pathogens were detected in one healthy control child each with the following combinations, viz., EPEC with Shigella, EPEC with STEC, and EPEC with O 157.
Overall analysis also showed statistically significant differences between detection rates for combinations of three infections concurrently among cases vs controls (p = 0.03917). There were two cases each under the following combinations with triple infection: (1) Rotavirus and Shigella with STEC; (2) Shigella and STEC with EPEC. Other combinations of triple infections were detected only in one child in each combination of concurrent infections (Table 7).
Comparison of the role of single infection vs multiple infections on average motions per day
No. of motions/day (min–max)
Mean average no
Two-sample independent t test
Equal variance (0.001015)**
More than one infections
Unequal variance (0.006885)**
Infectious diarrhea is a frequent problem in low-income countries which is a leading cause of death among children under 5 years of age . Though many different types of agents are reported to be associated with infectious diarrhea, DEC has however been known to be the most commonly diagnosed etiology in India . The overall result in our study showed that 56.92% of the children with diarrhea were diagnosed to be positive for at least one infectious etiology among the children with diarrhea. A study in the past showed E. coli (different strains) to be responsible for as much as 25% of all diarrheal diseases in developing countries . In this study, we also found DEC to be the most common diarrheal agent in the study population.
In the diarrheal group, more than 1 infectious agent was diagnosed in 44 (33.84%) cases. In our study, we found Rotavirus+Shigella to be the most frequent co-infection combination, while a previous study from Leon Nicaragua reported EAEC along with EPEC to be the most frequent co-infection .
The number of males suffering with diarrheal diseases was slightly more in comparison to females, which is similar to another study from India . Our study showed that at least one infectious etiology in diarrhea is more frequently detected among children living in rural settings than urban settings. This may be due to the poor hygiene and sanitation conditions of rural population that posses a high risk of infection among children as recommended earlier.
In this study, the major etiological agent was identified to be DEC followed by Rotavirus and Shigella in the age group of <2 years. Study elsewhere showed DEC being responsible for acute diarrhea in 30–40% of the affected children . EPEC, EAEC, and ETEC were the most common strains of E. coli detected in diarrheal diseases as reported elsewhere . In our study, EPEC was found more frequent than other DEC pathotypes, while in other studies EAEC was detected more frequently . Few studies have also highlighted the role of Shigella as an important etiological agent for diarrheal disease [33, 34]. In our study, we observed that Shigella was responsible for 23.84% of infection in children with acute diarrhea.
Rotavirus infection was associated with substantial hospitalization and deaths among children . In our study, we observed Rotavirus as the second leading cause of childhood diarrhea. Rotavirus was also present as multiple mixed infections with other diarrheal pathogens. Previously in a study from China, co-occurrence of Rotavirus and Sapovirus, Astrovirus, ETEC, or Campylobacter jejuni was observed in children . In this Chinese study, co-infections between pathogens were found to be common; especially the two pairs, Rotavirus and Adenovirus, and Norovirus GII and Salmonella were reported to be positively associated with diarrhea.
Cryptosporidium and Giardia were shown to affect children younger than five years of age in India . In this study, we observed that 4.61% of diarrheal cases were due to Cryptosporidium and 0.77% of cases ware due to Giardia. Giardia lamblia was not significantly associated with diarrhea in a study from Bangladesh .
Few studies from Africa have reported that almost one-third of studied children were infected with bacterial pathogens and about ten percent of them were co-infections [17, 38]. In our study, we observed that about 65.90% of cases have multiple infection in children <2 years of age. We could not observe any statistical significance among mono-infections and multiple infections with respect to age group between <2 years of age and 2–5 year age group (p = 0.32). A recent study from China reported viral–bacterial co-infection in <5-year-old children . In our study, we observed several mixed infections such as DEC with Shigella, Rotavirus with EPEC, and Rotavirus with Shigella. We observed that especially with Rotavirus and Adenovirus co-infections there was an increase in the diarrheal episodes per day.
Rotavirus co-infection with other enteric bacterial and protozoan pathogens was reported previously . In our study, mixed infections of Cryptosporidium with Rotavirus, Adenovirus, and EPEC were observed. Cryptosporidium infection was more frequently observed in <2 year age group in comparison to 2–5 year age group, although this was not statistically significant. We could not observe any association between Cryptosporidium infection along with vomiting and fever in the infected individuals. A synergistic effect between Rotavirus and other co-infecting pathogen(s) on diarrheal disease was also reported from a Latin American study .
Most studies of the causes of diarrhea in low-income and middle-income countries have looked at severe disease in people presenting for care, and there are few estimates of pathogen-specific diarrheal burdens in the community. In a recent cohort study, a substantial heterogeneity in pathogen-specific burdens of diarrhea was identified where the most important determinants were revealed to be age, geography, season, vaccine usage, and symptoms . Community screening was beyond scope of the present study. However, considering disease severity to be the most important criteria to access the possibility of a synergistic effect due to mixed infection in childhood diarrhea, in our study we could note an increased frequency of diarrheal episodes in cases that were diagnosed to have multiple infectious etiologies. A recent study from China also supports the above fact where virus–bacteria and virus–parasite co-infections are the aggravating factors of severe diarrhea in children .
There are limited number of studies in India, which can really enlighten on acute childhood diarrhea and far lesser in number when it comes to its bacterial enteropathogenesis. However, E. coli has been recorded as the predominant bacteria followed by Shigella, Salmonella, Klebsiella, and Campylobacter . A study from Bangladesh identified C. jejuni, ETEC, Shigella spp., and V. cholerae O1 as major bacterial pathogens that are significantly associated with diarrhea , while in our study EPEC and Shigella were found to be the most common diarrheal etiological agents.
Earlier studies support increased severity of diarrhea in the presence of Rotavirus-E. coli co-infection [41, 42]. Simultaneous interaction of Rotavirus and E. coli or Rotavirus and Shigella results in a greater risk of having diarrhea than would be expected if the co-infected organism acted independently of one another . Similar co-infection patterns of Rotavirus with E. coli and Rotavirus with Shigella were observed most predominately in our study population. Shigella along with several other types of bacteria has been shown to have a recycling mechanism for their peptidoglycan, which is designed to prevent its release and interact with Nod1 . In our study we found Shigella infection with different other diarrheal bacterial pathogens that may be the possible reason for disease severity in the patients.
At cellular and molecular level, diarrhea is simply an altered movement of ions and water. Enteric pathogens however can alter this balance towards net secretion. Together, co-infection might cause more severe diarrhea than infection with either pathogen alone . Specific co-infecting pathogens might also act synergistically resulting in even greater pathogenesis and a large contribution to an overall diarrheal disease burden. In our study, we found high prevalence of co-infection similar to the other studies reported previously [41–44]. Rotavirus is mainly responsible for decreased absorption without any significant intestinal inflammation, Shigella species causes inflammatory and invasive diarrhea and EPEC alters the intestinal epithelial integrity . We observed several mixed infections with all these three pathogens. On an average >10 diarrheal episodes/day in cases with concurrent infections might be due to an aggravated effect and a number of cellular mechanisms activated simultaneously by various pathogen factors. A true understanding of pathogenesis of diarrheal disease is incomplete without the thorough understanding of biological connections of these pathogens and synergistic interaction between co-infecting pathogens. We may be able to improve our understanding of the pathogenic potential of enteric infection consistently by distinguishing between single and mixed infection.
It is also important to include healthy controls in order to compare the distribution of exposure in healthy controls compared to cases as recommended elsewhere . The overall result in our study showed that 20.83% cases in non-diarrheal children also had at least one infectious agent as detected in the stool specimens. Reports originated from other studies also showed the detection of some of those agents in stool samples from human subjects with no symptoms of diarrhea [25, 26]. In the non-diarrheal group, only 3 (6.25%) subjects were found positive for multiple infections. However, it is not clear why those apparently normal individuals had the infectious agents but no symptoms of diarrhea was noticed. However, the frequency of detection of any diarrheal infectious agent or multiple agents in these apparently healthy subjects were much less, compared to those in case of the symptomatic subjects as supported on statistical analysis.
The overall finding on a broad spectrum of etiological agents of diarrhea and different combinations of concurrent infections in the pediatric patients will probably aid in planning future studies on various aspects of diarrheal diseases in this population. It is hypothesized that in cases with concurrent infections, different combinations of etiological agents might be complementing each other’s strategies of pathogenesis resulting in an increased disease severity, and other complications, which is a matter of concern.
This hospital-based study highlighted the overall burden of major bacterial, viral, and protozoan parasites in childhood diarrhea in the study region where multiple infections in nearly one-third of the cases pose a significant question to understand the synergistic role contributed by each associated pathogen in the overall pathogenesis of diarrheal diseases. Nevertheless, the results suggested that DEC strains such as EPEC and STEC, which are normally not screened routinely, should also be suspected in childhood diarrhea. Suspecting possible multiple infectious etiologies and diagnosis of the right causative agent(s) can help in a better pharmacological management of acute childhood diarrhea. Also it is recommended to address the issues of combined pathologies of co-existing diarrheagenic agents in experimental infection studies.
diarrheagenic Escherichia coli
enteropathogenic Escherichia coli
enterohemorrhagic Escherichia coli
shiga toxin-producing Escherichia coli
enteroaggregative Escherichia coli
polymerase chain reaction
World Health Organization
PSS, SK, and AKS designed the study. NKM was key in classifying cases and gathered patients’ clinical history and other relevant information. AKS collected specimens and performed the tests. NKM and PSS contributed to the patients’ diagnoses. AKS, SK, and PSS interpreted data and wrote the manuscript. MS did critical review of the manuscript. All authors read and approved the final manuscript.
The authors duly acknowledge Dr. Jyotiprakash Mishra (pediatrician) for his kind assistance in patient identification and sample collection. Authors are also thankful to Miss. Swagatika Panda for her help in the laboratory. The kind gift of standard Cryptosporidium genomic DNA from Prof. Gagandeep Kang, Christian Medical College, Vellore (India) is greatly acknowledged. We are also thankful to Prof. Adrian Hehl, Institute of Parasitology, University of Zurich for providing us the standard genomic DNA of Giardia used in this study.
The authors declare that they have no competing interests.
Availability of data and materials
Data will not be shared because the data generated out of patients contain personal information of the patients.
Ethics approval and consent to participate
All infants’ parents provided written informed consent, and this study was approved by the Ethical Committee of Kalinga Institute of Medical Sciences, KIIT University.
This study was supported by KIIT University. The Cryptosporidium and Giardia diagnostic reagents were used from the fund granted by Bill and Melinda Gates Foundation through a supplemental fund transfer to KIIT University from the University of California, Davis via the London School of Hygiene & Tropical Medicine under the Orissa Rural Sanitation Health Impact Trial (Registration No. NCT01214785).
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood diarrhoea and pneumonia. Lancet. 2013;381:1405–16.View ArticlePubMedGoogle Scholar
- Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: current scenario and future perspectives. J Nat Sci Biol Med. 2015;6:24.View ArticlePubMedPubMed CentralGoogle Scholar
- Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet. 2013;382:209–22.View ArticlePubMedGoogle Scholar
- Kotloff KL, Blackwelder WC, Nasrin D, Nataro JP, Farag TH, Van Eijk A, et al. The Global Enteric Multicenter Study (GEMS) of diarrheal disease in infants and young children in developing countries: epidemiologic and clinical methods of the case/control study. Clin Infect Dis. 2012;55:S232.View ArticlePubMedPubMed CentralGoogle Scholar
- O’Ryan M, Prado V, Pickering LK. A millennium update on pediatric diarrheal illness in the developing world. Semin Pediatr Infect Dis. 2005;16:125–36.View ArticlePubMedGoogle Scholar
- Batabyal P, Mookerjee S, Sur D, Palit A. Diarrheogenic Escherechia coli in potable water sources of West Bengal, India. Acta Trop. 2013;127:153–7.View ArticlePubMedGoogle Scholar
- Kawai K, O’Brien MA, Goveia MG, Mast TC, El Khoury AC. Burden of rotavirus gastroenteritis and distribution of rotavirus strains in Asia: a systematic review. Vaccine. 2012;30(7):1244–54.View ArticlePubMedGoogle Scholar
- Livio S, Strockbine NA, Panchalingam S, Tennant SM, Barry EM, Marohn ME, et al. Shigella isolates from the global enteric multicenter study inform vaccine development. Clin Infect Dis. 2014;59:933–41.View ArticlePubMedPubMed CentralGoogle Scholar
- Tate JE, Burton AH, Boschi-Pinto C, Steele AD, Duque J, Parashar UD. 2008 estimate of worldwide rotavirus-associated mortality in children younger than 5 years before the introduction of universal rotavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12:136–41.View ArticlePubMedGoogle Scholar
- Tate JE, Burton AH, Boschi-Pinto C, Parashar UD. Global, regional, and national estimates of rotavirus mortality in children < 5 years of age, 2000–2013. Clin Infect Dis. 2016;62:S96–105.View ArticlePubMedGoogle Scholar
- Langendorf C, Le Hello S, Moumouni A, Gouali M, Mamaty AA, Grais RF, et al. Enteric bacterial pathogens in children with diarrhea in Niger: diversity and antimicrobial resistance. PLoS ONE. 2015;10:1–18.View ArticleGoogle Scholar
- Bardhan P, Faruque ASG, Naheed A, Sack DA. Decrease in shigellosis-related deaths without Shigella spp.-specific interventions, Asia. Emerg Infect Dis. 2010;16:1718–23.View ArticlePubMedPubMed CentralGoogle Scholar
- Zhu JY, Duan GC, Yang HY, Fan QT, Xi YL. Atypical class 1 integron coexists with class 1 and class 2 integrons in multi-drug resistant Shigella flexneri isolates from China. Curr Microbiol. 2011;62:802–6.View ArticlePubMedGoogle Scholar
- Sarkar R, Tate JE, Ajjampur SSR, Kattula D, John J, Ward HD, et al. Burden of diarrhea, hospitalization and mortality due to cryptosporidial infections in Indian children. PLoS Negl Trop Dis. 2014;8:e3042.View ArticlePubMedPubMed CentralGoogle Scholar
- Norhayati M, Fatmah MS, Yusof S, Edariah AB. Intestinal parasitic infections in man: a review. Med J Malays. 2003;58(2):296–305.Google Scholar
- Gasparinho C, Mirante MC, Centeno-Lima S, Istrate C, Mayer AC, Tavira L, et al. Etiology of diarrhea in children younger than 5 years attending the Bengo General Hospital in Angola. Pediatr Infect Dis J. 2016;35:e28–34.View ArticlePubMedGoogle Scholar
- Bonkoungou IJO, Haukka K, Österblad M, Hakanen AJ, Traoré AS, Barro N, et al. Bacterial and viral etiology of childhood diarrhea in Ouagadougou, Burkina Faso. BMC Pediatr. 2013;13:36.View ArticlePubMedPubMed CentralGoogle Scholar
- Sambe-Ba B, Espié E, Faye ME, Timbiné LG, Sembene M, Gassama-Sow A. Community-acquired diarrhea among children and adults in urban settings in Senegal: clinical, epidemiological and microbiological aspects. BMC Infect Dis. 2013;13:580.View ArticlePubMedPubMed CentralGoogle Scholar
- Mukherjee AK, Chowdhury P, Rajendran K, Nozaki T, Ganguly S. Association between Giardia duodenalis and coinfection with other diarrhea-causing pathogens in India. Biomed Res Int. 2014. doi:10.1155/2014/786480.Google Scholar
- Mladenova Z, Steyer A, Steyer AF, Ganesh B, Petrov P, Tchervenjakova T, et al. Aetiology of acute paediatric gastroenteritis in Bulgaria during summer months: prevalence of viral infections. J Med Microbiol. 2015;64:272–82.View ArticlePubMedGoogle Scholar
- Bhavnani D, Goldstick JE, Cevallos W, Trueba G, Eisenberg JNS. Synergistic effects between rotavirus and coinfecting pathogens on diarrheal disease: evidence from a community-based study in northwestern Ecuador. Am J Epidemiol. 2012;176:387–95.View ArticlePubMedPubMed CentralGoogle Scholar
- Elhag WI, Saeed HA, Omer EFE, Ali AS. Prevalence of rotavirus and adenovirus associated with diarrhea among displaced communities in Khartoum, Sudan. BMC Infect Dis. 2013;13:209.View ArticlePubMedPubMed CentralGoogle Scholar
- Vilchez S, Reyes D, Paniagua M, Bucardo F, Möllby R, Weintraub A. Prevalence of diarrhoeagenic Escherichia coli in children from León, Nicaragua. J Med Microbiol. 2009;58:630–7.View ArticlePubMedGoogle Scholar
- Paton AW, Paton JC. Detection and characterization of shiga toxigenic escherichia coli by using multiplex PCR assays for stx1, stx2, eaeA, enterohemorrhagic E. coli hlyA, rfb(O111), and rfb(O157). J Clin Microbiol. 1998;36:598–602.PubMedPubMed CentralGoogle Scholar
- de Freitas CG, Santana ÂP, da Silva PHC, Gonçalves VSP, Barros MD, Torres FA, et al. PCR multiplex for detection of Salmonella Enteritidis, Typhi and Typhimurium and occurrence in poultry meat. Int J Food Microbiol. 2010;139(15–22):26.Google Scholar
- Boschi-Pinto C, Velebit L, Shibuya K. Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ. 2008;86:710–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Hossain MT, Kim EY, Kim YR, Kim DG, Kong IS. Development of a groEL gene-based species-specific multiplex polymerase chain reaction assay for simultaneous detection of Vibrio cholerae, Vibrio parahaemolyticus and Vibrio vulnificus. J Appl Microbiol. 2013;114:448–56.View ArticlePubMedGoogle Scholar
- Morgan UM, Constantine CC, Forbes DA. Differentiation between human and animal isolates of Cryptosporidium parvum using rDNA sequencing and direct PCR analysis. J Parasitol. 1997;83:825–30.View ArticlePubMedGoogle Scholar
- Read CM, Monis PT, Thompson RCA. Discrimination of all genotypes of Giardia duodenalis at the glutamate dehydrogenase locus using PCR-RFLP. Infect Genet Evol. 2004;4:125–30.View ArticlePubMedGoogle Scholar
- Rathaur VK, Pathania M, Jayara A, Yadav N. Clinical study of acute childhood diarrhoea caused by bacterial enteropathogens. J Clin Diagn Res. 2014;8:PC01–5.PubMedPubMed CentralGoogle Scholar
- Niyogi SK, Saha MR, De SP. Enteropathogens associated with acute diarrhoeal diseases. Indian J Public Health. 1994;38:29–32.PubMedGoogle Scholar
- Hegde A, Ballal MSS. Detection of diarrheagenic Escherichia coli by multiplex PCR. Indian J Med Microbiol. 2012;1:279.View ArticleGoogle Scholar
- Breurec S, Vanel N, Bata P, Chartier L, Farra A, Favennec L, et al. Etiology and epidemiology of diarrhea in hospitalized children from low income country: a matched case–control study in Central African Republic. PLoS Negl Trop Dis. 2016;10:e0004283.View ArticlePubMedPubMed CentralGoogle Scholar
- George CM, Ahmed S, Talukder KA, Azmi IJ, Perin J, Sack RB, et al. Shigella infections in household contacts of pediatric shigellosis patients in rural Bangladesh. Emerg Infect Dis. 2015;21:2006–13.View ArticlePubMedPubMed CentralGoogle Scholar
- Li LL, Liu N, Humphries EM, Yu JM, Li S, Lindsay BR, et al. Aetiology of diarrhoeal disease and evaluation of viral-bacterial coinfection in children under 5 years old in China: a matched case-control study. Clin Microbiol Infect. 2016;22:381.e9–16.View ArticleGoogle Scholar
- Daniels ME, Shrivastava A, Smith WA, Sahu P, Odagiri M, Misra PR, et al. Cryptosporidium and giardia in humans, domestic animals, and village water sources in rural India. Am J Trop Med Hyg. 2015;93:596–600.View ArticlePubMedPubMed CentralGoogle Scholar
- Albert MJ, Faruque AS, Faruque SM, Sack RB, Mahalanabis D. Case-control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. J Clin Microbiol. 1999;37(11):3458–64.PubMedPubMed CentralGoogle Scholar
- Nitiema LW, Nordgren J, Ouermi D, Dianou D, Traore AS, Svensson L, et al. Burden of rotavirus and other enteropathogens among children with diarrhea in Burkina Faso. Int J Infect Dis. 2011;15:e646.View ArticlePubMedGoogle Scholar
- Zhang SX, Zhou YM, Xu W, Tian LG, Chen JX, Chen SH, Dang ZS, Gu WP, Yin JW, Serrano EZX. Impact of co-infections with enteric pathogens on children suffering from acute diarrhea in southwest China. Infect Dis Poverty. 2016;5:64.View ArticlePubMedPubMed CentralGoogle Scholar
- Platts-Mills JA, Babji S, Bodhidatta L, Gratz J, Haque R, Havt A, et al. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED). Lancet Glob Health. 2015;3:e564.View ArticlePubMedGoogle Scholar
- Hori H, Akpedonu P, Armah G, Aryeetey M, Yartey J, Kamiya H, et al. Enteric pathogens in severe forms of acute gastroenteritis in Ghanaian children. Pediatr Int. 1996;38:672–6.View ArticleGoogle Scholar
- Velázquez FR, Matson DO, Calva JJ, Guerrero ML, Morrow AL, Carter-Campbell S, Glass RI, Estes MK, Pickering LK, Ruiz-Palacios GM. Rotavirus infection in infants as protection against subsequent infections. N Engl J Med. 1996;335(14):1022–8.View ArticlePubMedGoogle Scholar
- Hodges K, Gill R. Infectious diarrhea: cellular and molecular mechanisms. Gut Microbes. 2010;1(1):4–21.View ArticlePubMedPubMed CentralGoogle Scholar
- Bodhidatta L, McDaniel P, Sornsakrin S, Srijan A, Serichantalergs O, Mason CJ. Case-Control Study of diarrheal disease etiology in a remote rural area in western Thailand. Am J Trop Med Hyg. 2010;83:1106–9.View ArticlePubMedPubMed CentralGoogle Scholar