Gastrointestinal Infections and Diarrheal Disease in Ghanaian Infants and Children: An Outpatient Case-Control Study

<div><p>Introduction</p><p>Diarrheal diseases are among the most frequent causes of morbidity and mortality in children worldwide, especially in resource-poor areas. This case-control study assessed the associations between gastrointestinal infections and diarrhea in children from rural Ghana.</p><p>Methods</p><p>Stool samples were collected from 548 children with diarrhea and from 686 without gastrointestinal symptoms visiting a hospital from 2007–2008. Samples were analyzed by microscopy and molecular methods.</p><p>Results</p><p>The organisms most frequently detected in symptomatic cases were <i>Giardia lamblia</i>, <i>Shigella</i> spp./ enteroinvasive <i>Escherichia coli</i> (EIEC), and <i>Campylobacter jejuni</i>. Infections with rotavirus (adjusted odds ratio [aOR] = 8.4; 95% confidence interval [CI]: 4.3–16.6), <i>C</i>. <i>parvum/hominis</i> (aOR = 2.7; 95% CI: 1.4–5.2) and norovirus (aOR = 2.0; 95%CI: 1.3–3.0) showed the strongest association with diarrhea. The highest attributable fractions (AF) for diarrhea were estimated for rotavirus (AF = 14.3%; 95% CI: 10.9–17.5%), <i>Shigella</i> spp./EIEC (AF = 10.5%; 95% CI: 3.5–17.1%), and norovirus (AF = 8.2%; 95% CI 3.2–12.9%). Co-infections occurred frequently and most infections presented themselves independently of other infections. However, infections with <i>E</i>. <i>dispar</i>, <i>C</i>. <i>jejuni</i>, and norovirus were observed more often in the presence of <i>G</i>. <i>lamblia</i>.</p><p>Conclusions</p><p>Diarrheal diseases in children from a rural area in sub-Saharan Africa are mainly due to infections with rotavirus, <i>Shigella</i> spp./EIEC, and norovirus. These associations are strongly age-dependent, which should be considered when diagnosing causes of diarrhea. The presented results are informative for both clinicians treating gastrointestinal infections as well as public health experts designing control programs against diarrheal diseases.</p></div

Crude odds ratio (OR), age-adjusted OR (aOR), and age-stratified OR on associations between gastrointestinal infections and diarrhea, sorted by aOR.

<p>Abbreviations: OR, odds ratio; CI, confidence interval; aOR, age-adjusted odds ratio.</p><p>^§Combined age groups to avoid empty cells in cross-tabulation.</p><p>Crude odds ratio (OR), age-adjusted OR (aOR), and age-stratified OR on associations between gastrointestinal infections and diarrhea, sorted by aOR.</p

Age-adjusted relative risk of the occurrences of selected gastrointestinal co-infections in all children and for cases and controls separately.

<p>Abbreviations: aRR, age-adjusted risk ratio; CI, confidence interval; NA: not applicable due to low frequency.</p><p>Age-adjusted relative risk of the occurrences of selected gastrointestinal co-infections in all children and for cases and controls separately.</p

Proportions of case and control children by age group infected by various organisms.

<p>All organisms detected in more than 50 samples are shown. Median ages in months (IQR) at the time of infection are shown in brackets.</p

Characteristics of the total populations and stratified groups of case and control children.

<p>Abbreviations: IQR, interquartile range; SD, standard deviation; DPT/HIB/Hep B1/Pol: diphtheria, pertussis, and tetanus/Haemophilus influenzae type B/Hepatitis B/Polio; NA, not applicable.</p><p>^#Per child (N = 1,168,)</p><p>^§Per visit (N = 1,234)</p><p>Missing values (not considered in percentages):</p><p>^a91,</p><p>^b76</p><p>^c6,</p><p>^d8,</p><p>^e9s,</p><p>^f383.</p><p>Frequency (per cent) presented if not specified otherwise.</p><p>Characteristics of the total populations and stratified groups of case and control children.</p

Frequencies (per cent) of gastrointestinal organisms identified in stool samples sorted by species group and frequency of occurrence.

<p>Missing values (not considered in percentages):</p><p>^a225;</p><p>^b224,</p><p>^c218,</p><p>^d602,</p><p>^e213,</p><p>^f217</p><p>^$identified via Polymerase Chain Reaction (PCR)</p><p>^§identified via ELISA</p><p>Frequencies (per cent) of gastrointestinal organisms identified in stool samples sorted by species group and frequency of occurrence.</p