Comprehensive Analysis of Prevalence, Epidemiologic Characteristics, and Clinical Characteristics of Monoinfection and Coinfection in Diarrheal Diseases in Children in Tanzania

Abstract

The role of interactions between intestinal pathogens in diarrheal disease is uncertain. From August 2010 to July 2011, we collected stool samples from 723 children admitted with diarrhea (cases) to 3 major hospitals in Dar es Salaam, Tanzania, and from 564 nondiarrheic children (controls). We analyzed the samples for 17 pathogens and assessed interactions between coinfections in additive and multiplicative models. At least one pathogen was detected in 86.9% of the cases and 62.8%, of the controls. Prevalence of coinfections was 58.1% in cases and 40.4% in controls. Rotavirus, norovirus genogroup II, Cryptosporidium, and Shigella species/enteroinvasive Escherichia coli were significantly associated with diarrhea both as monoinfections and as coinfections. In the multiplicative interaction model, we found 2 significant positive interactions: rotavirus + Giardia (odds ratio (OR) = 23.91, 95% confidence interval (CI): 1.21, 470.14) and norovirus GII + enteroaggregative E. coli (OR = 3.06, 95% CI: 1.17, 7.98). One significant negative interaction was found between norovirus GII + typical enteropathogenic E. coli (OR = 0.09, 95% CI: 0.01, 0.95). In multivariate analysis, risk factors for death were presence of blood in stool and severe dehydration. In conclusion, coinfections are frequent, and the pathogenicity of each organism appears to be enhanced by some coinfections and weakened by others. Severity of diarrhea was not affected by coinfections.

Keywords: biological interactions; coinfections; diarrheal disease; monoinfections; pathogenicity.

Figure 1.

The number of enteric pathogens detected per child for cases with diarrhea and for controls, Dar es Salaam, Tanzania, 2010–2011. Number of pathogens detected ranged from 0 to 6 pathogens per child in cases and 0 to 5 pathogens per child in controls. The y-axis represents the percentage of children. In the regression analysis, the odds of having 2 or more pathogens were significantly higher among cases than among controls and were as follows: for 2 pathogens, odds ratio = 5.21 (95% confidence interval (CI): 3.72, 7.29); for 3 pathogens, odds ratio = 5.7 (95% CI: 3.65, 8.91); for 4 pathogens, odds ratio = 19.89 (95% CI: 4.52, 87.47), and for 5 pathogens, odds ratio = 7.37 (95% CI: 1.98, 27.38).