Astrovirus Infection and Diarrhea in 8 Countries

Abstract

Background and objectives: Astroviruses are important drivers of viral gastroenteritis but remain understudied in community settings and low- and middle-income countries. We present data from 8 countries with high prevalence of diarrhea and undernutrition to describe astrovirus epidemiology and assess evidence for protective immunity among children 0 to 2 years of age.

Methods: We used 25 898 surveillance stools and 7077 diarrheal stools contributed by 2082 children for enteropathogen testing, and longitudinal statistical analysis to describe incidence, risk factors, and protective immunity.

Results: Thirty-five percent of children experienced astrovirus infections. Prevalence in diarrheal stools was 5.6%, and severity exceeded all enteropathogens except rotavirus. Incidence of infection and diarrhea were 2.12 and 0.88 episodes per 100 child-months, respectively. Children with astrovirus infection had 2.30 times the odds of experiencing diarrhea after adjustment for covariates (95% confidence interval [CI], 2.01-2.62; P < .001). Undernutrition was a risk factor: odds of infection and diarrhea were reduced by 10% and 13%, respectively, per increase in length-for-age z score (infection: odds ratio, 0.90 [95% CI, 0.85-0.96]; P < .001; diarrhea: odds ratio, 0.87 [95% CI, 0.79-0.96]; P = .006). Some evidence of protective immunity to infection was detected (hazard ratio, 0.84 [95% CI, 0.71-1.00], P = .052), although this was heterogeneous between sites and significant in India and Peru.

Conclusions: Astrovirus is an overlooked cause of diarrhea among vulnerable children worldwide. With the evidence presented here, we highlight the need for future research as well as the potential for astrovirus to be a target for vaccine development.

FIGURE 1

Cumulative incidence of astrovirus in (A) surveillance stools and (B) diarrheal samples in the MAL-ED cohort. Time to first infection and clinical episode of diarrhea is shown globally (black dotted line) and separately by site. BGD: Mirpur, Bangladesh; BRF: Fortaleza, Brazil; INV: Vellore, India; NEB: Bhaktapur, Nepal; PEL: Iquitos, Peru; PKN: Naushero Feroze, Pakistan; SAV: Limpopo, South Africa; TZH: Heydom, Tanzania.

FIGURE 2

Astrovirus prevalence by (A) age and (B) site across 2082 children in the MAL-ED cohort. Surveillance stools are shown in red, and diarrheal samples are shown in blue. BGD: Mirpur, Bangladesh; BRF: Fortaleza, Brazil; INV: Vellore, India; NEB: Bhaktapur, Nepal; PEL: Iquitos, Peru; PKN: Naushero Feroze, Pakistan; SAV: Limpopo, South Africa; TZH: Heydom, Tanzania.