Platts-Mills James A, Babji Sudhir, Bodhidatta Ladaporn, Gratz Jean, Haque Rashidul, Havt Alexandre, McCormick Benjamin Jj, McGrath Monica, Olortegui Maribel Paredes, Samie Amidou, Shakoor Sadia, Mondal Dinesh, Lima Ila Fn, Hariraju Dinesh, Rayamajhi Bishnu B, Qureshi Shahida, Kabir Furqan, Yori Pablo P, Mufamadi Brenda, Amour Caroline, Carreon J Daniel, Richard Stephanie A, Lang Dennis, Bessong Pascal, Mduma Esto, Ahmed Tahmeed, Lima Aldo Aam, Mason Carl J, Zaidi Anita Km, Bhutta Zulfiqar A, Kosek Margaret, Guerrant Richard L, Gottlieb Michael, Miller Mark, Kang Gagandeep, Houpt Eric R
Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
Christian Medical College, Vellore, India.
Lancet Glob Health. 2015 Sep;3(9):e564-75. doi: 10.1016/S2214-109X(15)00151-5. Epub 2015 Jul 19.
Most studies of the causes of diarrhoea 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 diarrhoea burdens in the community.
We undertook a birth cohort study with not only intensive community surveillance for diarrhoea but also routine collection of non-diarrhoeal stools from eight sites in South America, Africa, and Asia. We enrolled children within 17 days of birth, and diarrhoeal episodes (defined as maternal report of three or more loose stools in 24 h, or one loose stool with visible blood) were identified through twice-weekly home visits by fieldworkers over a follow-up period of 24 months. Non-diarrhoeal stool specimens were also collected for surveillance for months 1-12, 15, 18, 21, and 24. Stools were analysed for a broad range of enteropathogens using culture, enzyme immunoassay, and PCR. We used the adjusted attributable fraction (AF) to estimate pathogen-specific burdens of diarrhoea.
Between November 26, 2009, and February 25, 2014, we tested 7318 diarrhoeal and 24 310 non-diarrhoeal stools collected from 2145 children aged 0-24 months. Pathogen detection was common in non-diarrhoeal stools but was higher with diarrhoea. Norovirus GII (AF 5·2%, 95% CI 3·0-7·1), rotavirus (4·8%, 4·5-5·0), Campylobacter spp (3·5%, 0·4-6·3), astrovirus (2·7%, 2·2-3·1), and Cryptosporidium spp (2·0%, 1·3-2·6) exhibited the highest attributable burdens of diarrhoea in the first year of life. The major pathogens associated with diarrhoea in the second year of life were Campylobacter spp (7·9%, 3·1-12·1), norovirus GII (5·4%, 2·1-7·8), rotavirus (4·9%, 4·4-5·2), astrovirus (4·2%, 3·5-4·7), and Shigella spp (4·0%, 3·6-4·3). Rotavirus had the highest AF for sites without rotavirus vaccination and the fifth highest AF for sites with the vaccination. There was substantial variation in pathogens according to geography, diarrhoea severity, and season. Bloody diarrhoea was primarily associated with Campylobacter spp and Shigella spp, fever and vomiting with rotavirus, and vomiting with norovirus GII.
There was substantial heterogeneity in pathogen-specific burdens of diarrhoea, with important determinants including age, geography, season, rotavirus vaccine usage, and symptoms. These findings suggest that although single-pathogen strategies have an important role in the reduction of the burden of severe diarrhoeal disease, the effect of such interventions on total diarrhoeal incidence at the community level might be limited.
大多数关于低收入和中等收入国家腹泻病因的研究都关注就医人群中的严重腹泻疾病，而对社区中病原体特异性腹泻负担的估计较少。
我们开展了一项出生队列研究，不仅对腹泻进行强化社区监测，还从南美洲、非洲和亚洲的八个地点常规收集非腹泻粪便。我们纳入出生17天内的儿童，通过现场工作人员每两周一次的家访，在24个月的随访期内确定腹泻发作情况（定义为母亲报告24小时内有三次或更多次稀便，或一次带可见血的稀便）。在第1 - 12个月、15个月、18个月、21个月和24个月也收集非腹泻粪便标本进行监测。使用培养、酶免疫测定和聚合酶链反应对粪便进行多种肠道病原体分析。我们使用调整后的归因分数（AF）来估计病原体特异性腹泻负担。
在2009年11月26日至2014年2月25日期间，我们检测了从2145名0 - 24个月大儿童收集的7318份腹泻粪便和24310份非腹泻粪便。病原体检测在非腹泻粪便中很常见，但腹泻时更高。诺如病毒GII（AF 5.2%，95%CI 3.0 - 7.1）、轮状病毒（4.8%，4.5 - 5.0）、弯曲杆菌属（3.5%，0.4 - 6.3）、星状病毒（2.7%，2.2 - 3.1）和隐孢子虫属（2.0%，1.3 - 2.6）在生命的第一年表现出最高的腹泻归因负担。生命第二年与腹泻相关的主要病原体是弯曲杆菌属（7.9%，3.1 - 12.1）、诺如病毒GII（5.4%，2.1 - 7.8）、轮状病毒（4.9%，4.4 - 5.2）、星状病毒（4.2%，3.5 - 4.7）和志贺菌属（4.0%，3.6 - 4.3）。对于未接种轮状病毒疫苗的地点，轮状病毒的AF最高，对于接种疫苗的地点，轮状病毒的AF排第五。病原体因地理位置、腹泻严重程度和季节而有很大差异。血性腹泻主要与弯曲杆菌属和志贺菌属相关，发热和呕吐与轮状病毒有关联，呕吐与诺如病毒GII有关联。
腹泻的病原体特异性负担存在很大异质性，重要的决定因素包括年龄、地理位置、季节、轮状病毒疫苗使用情况和症状。这些发现表明，尽管单一病原体策略在减轻严重腹泻疾病负担方面具有重要作用，但此类干预措施对社区层面总腹泻发病率的影响可能有限。
