Burden and Distribution of Protozoan Pathogens in Diarrhea Cases Worldwide: A Systematic Review and Meta-Analysis, 1999-2024

Joseph B Suleiman; Maryam Azlan

doi:10.7759/cureus.91561

. 2025 Sep 3;17(9):e91561. doi: 10.7759/cureus.91561

Burden and Distribution of Protozoan Pathogens in Diarrhea Cases Worldwide: A Systematic Review and Meta-Analysis, 1999-2024

Joseph B Suleiman ^1,², Maryam Azlan ^1,^✉

Editors: Alexander Muacevic, John R Adler

PMCID: PMC12494489 PMID: 41049918

Abstract

Protozoan pathogens are significant contributors to global diarrheal morbidity and mortality, particularly in resource-limited settings. Despite their clinical importance, the global burden and geographic distribution of protozoan-related diarrhea remain incompletely characterized. This study aimed to quantify the prevalence and regional trends of key protozoan pathogens in diarrheal cases globally from 1999 to 2024. A comprehensive systematic review and meta-analysis were conducted following PRISMA guidelines. Five databases (PubMed, Scopus, Google Scholar, Web of Science, and ScienceDirect) were searched for studies reporting the prevalence of Giardia duodenalis, Entamoeba histolytica, Cryptosporidium spp., Blastocystis hominis, and Cyclospora cayetanensis in patients with diarrhea. Random-effects models were used to estimate pooled prevalence, with subgroup analyses by region, age, diagnostic method, and socioeconomic indicators. Heterogeneity and publication bias were assessed using meta-regression and funnel plots. Results of the meta-analysis of 73 studies revealed a global protozoan prevalence of 7.5% (95% CI: 5.6%-10.0%) in diarrheal cases, with the highest rates in the Americas and Africa. Giardia and Cryptosporidium were the most common pathogens. Despite substantial heterogeneity and some small-study bias, findings were robust, with minimal publication bias and variation due to diagnostic methods used. Protozoan pathogens remain major yet underrecognized drivers of diarrheal disease worldwide. Targeted interventions, including improved diagnostics, sanitation, and surveillance, are essential to mitigate their impact.

Keywords: diarrhea, meta analysis, pathogens, protozoa, systematic review

Introduction and background

Diarrheal diseases caused by protozoan pathogens represent a persistent global health challenge, particularly in resource-limited settings where poor sanitation and inadequate water infrastructure facilitate transmission [1-3]. Among the most clinically significant enteric protozoa, Cryptosporidium spp., Giardia duodenalis, and Entamoeba histolytica collectively account for an estimated 500 million annual diarrheal cases worldwide, contributing substantially to childhood morbidity, malnutrition, and developmental delays [4-6]. These pathogens disproportionately affect children under five in low- and middle-income countries (LMICs), where they are responsible for 10-15% of diarrheal deaths and are increasingly recognized as contributors to long-term growth faltering and cognitive impairment [7,8]. Despite their significant disease burden, protozoan enteropathogens remain understudied compared to bacterial and viral agents, with critical gaps in our understanding of their spatiotemporal distribution, zoonotic transmission dynamics, and interactions with environmental and socioeconomic factors [8].

The epidemiology of protozoan enteric infections reveals striking geographical disparities. Cryptosporidium alone causes approximately 200,000 deaths annually, with the highest burden in sub-Saharan Africa and South Asia [9,10]. Recent studies demonstrate that cryptosporidiosis is associated with a 2-3 times higher risk of mortality in malnourished children compared to other diarrheal etiologies [11-13]. Giardia infections, while less frequently fatal, affect an estimated 280 million people each year and are linked to chronic malnutrition, micronutrient deficiencies, and post-infectious irritable bowel syndrome [14,15]. Entamoeba histolytica, though geographically more restricted, remains a significant cause of dysentery and extra-intestinal complications, particularly in Central and South America and parts of Asia [15]. The true burden of these pathogens is likely underestimated due to diagnostic challenges, with microscopy-based surveillance missing 30-50% of cases detectable by molecular methods [16].

Protozoan enteropathogens exhibit complex transmission patterns influenced by environmental, climatic, and anthropogenic factors. Cryptosporidium oocysts and Giardia cysts are remarkably resistant to standard water treatment methods, leading to frequent waterborne outbreaks even in high-income countries [17]. Climate change is altering transmission dynamics, with studies linking increased rainfall intensity to Cryptosporidium outbreaks and drought conditions to Giardia proliferation [18]. Zoonotic transmission plays a significant role, particularly for Cryptosporidium parvum and Giardia assemblages with animal reservoirs, creating challenges for One Health approaches to disease control [19]. Similarly, urbanization has introduced new transmission patterns, with dense informal settlements creating ideal conditions for person-to-person spread of Entamoeba histolytica [20]. Some enteric protozoans, their global prevalence, and associated health risks are summarized in Table 1.

Table 1. Global prevalence and health risks of enteric protozoa and related organisms.

Enteric organisms	Global prevalence	Effects on humans	Risk level
Cyclospora cayetanensis	Rare (<1%); outbreaks in Latin America, Asia, USA	Causes prolonged watery diarrhea, abdominal cramps, fatigue	Pathogenic
Cystoisospora belli (formerly Isospora belli)	Very rare (<0.5%); mostly in tropics	Severe diarrhea in immunocompromised individuals (e.g., HIV/AIDS)	Opportunistic pathogen
Giardia duodenalis (syn. G. lamblia)	Common: 2-7% in developed, 30-40% in developing countries	Giardiasis - watery diarrhea, bloating, malabsorption	Pathogenic
Blastocystis spp. (formerly B. hominis)	Very common: 10-60% worldwide	Sometimes causes diarrhea and abdominal pain; often asymptomatic	Possibly pathogenic
Entamoeba histolytica	About 1-2% true infections (10% carry Entamoeba species)	Amoebiasis - bloody diarrhea, dysentery, liver abscess	Pathogenic
Cryptosporidium parvum	1-4% worldwide; up to 10% in children in low-income regions	Severe watery diarrhea; life-threatening in immunocompromised patients	Pathogenic
Endolimax nana	Very common: up to 30-40%	Harmless; indicator of poor hygiene/fecal exposure	Nonpathogenic
Entamoeba hartmanni	Common: 5-10%	Harmless; resembles E. histolytica microscopically	Nonpathogenic
Chilomastix mesnili	Found in ~5%	Harmless intestinal commensal	Nonpathogenic
Pentatrichomonas hominis (formerly Trichomonas hominis)	Fairly common: 1-10%	Harmless intestinal commensal	Nonpathogenic

Open in a new tab

Furthermore, the advent of molecular diagnostics has revolutionized protozoan detection, revealing higher prevalence rates and more frequent polyparasitism than previously recognized. Multiplex PCR studies demonstrate that 15-25% of diarrheal cases in endemic areas involve protozoan co-infections, often alongside bacterial or viral pathogens [20,21]. Despite these diagnostic advances, treatment options remain limited, nitazoxanide is the only FDA-approved drug for cryptosporidiosis, and resistance is emerging [22]. The lack of vaccines for any protozoan enteropathogen underscores the critical need for preventive strategies targeting water, sanitation, and hygiene (WASH) interventions [23]. Recent trials of monoclonal antibodies for cryptosporidiosis prevention show promise but face implementation challenges in high-burden settings [24,25].

Review

Methodology

Search Strategy and Data Sources

A systematic literature search was conducted across five major electronic databases: Google Scholar, PubMed, Scopus, Web of Science, and ScienceDirect. The search strategy was structured around three primary concept clusters: (1) terms related to co-infection (e.g., “Coinfection,” “Concurrent infection,” “Dual infection,” “Mixed infection”), (2) specific pathogens (e.g., Vibrio cholerae, Shigella spp., Enteropathogenic E. coli, Rotavirus, Norovirus, Cryptosporidium, Giardia), and (3) epidemiological measures (e.g., “Prevalence,” “Incidence,” “Burden,” “Epidemiology”). No restrictions were imposed regarding language, publication date, or study design. The final search update, completed on December 30, 2024, identified 1,133 potentially eligible articles.

Study Design and Registration

This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol was prospectively registered with PROSPERO (registration ID: CRD420251060392) to enhance methodological transparency and minimize research duplication. The review aimed to assess the global prevalence of protozoan enteric pathogens in diarrheal cases reported from January 1999 through December 2024.

Study Selection and Eligibility Criteria

Inclusion criteria: Eligible studies met the following criteria: (1) original research articles reporting laboratory-confirmed detection of enteric pathogens, (2) inclusion of at least two identified pathogens per diarrheal case, and (3) population-based studies with clearly defined diagnostic methods and data collected between 1999 and 2024.

Exclusion criteria: The following were excluded: reviews, editorials, case reports, and other non-primary research; studies focused solely on animals or environmental samples; articles with incomplete prevalence data or ambiguous diagnostic methods; and duplicate publications based on overlapping datasets.

Screening Process

Two independent reviewers screened titles and abstracts, followed by full-text assessments of potentially relevant articles. Discrepancies were resolved through consensus discussions within the research team. The selection process was documented using a PRISMA flow diagram.

Data extraction and management

Data were extracted using a standardized form capturing study characteristics (e.g., author, year, country, study design), population details (e.g., sample size, age distribution, clinical features), and pathogen information (e.g., detection methods, co-infection rates, sampling strategies, laboratory protocols). Two researchers independently verified the extracted data to ensure consistency and accuracy.

Quality assessment

The methodological quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Prevalence Studies, covering nine key domains. Studies scoring ≥7 out of 9 were deemed high quality and included in the quantitative synthesis. Quality assessments were conducted independently by two reviewers, achieving strong inter-rater agreement (Cohen’s κ = 0.82). Further details are provided in Appendix 1.

Statistical analysis

Meta-analysis Approach

Random-effects meta-analyses using the DerSimonian-Laird method were performed to account for heterogeneity between studies. Pooled prevalence estimates were calculated using inverse-variance weighting. Subgroup analyses were conducted based on pathogen type, geographical region, and time period.

Heterogeneity and Publication Bias

Statistical heterogeneity was quantified using the I² statistic, with thresholds of 25%, 50%, and 75% representing low, moderate, and high heterogeneity, respectively. Publication bias was assessed via funnel plot asymmetry and Egger’s regression test. Sensitivity analyses were conducted by sequentially excluding individual studies to assess the robustness of the results.

Software Tools

Primary meta-analyses were conducted using OpenMeta[Analyst]. Jamovi version 2.3.28 was used for publication bias assessments, while meta-regression analyses were performed using OpenMEE software. In addition, MapChart software was used to design and visualize the global distribution maps of protozoan enteropathogens.

Ethical considerations

This study relied solely on previously published, de-identified data and therefore did not require formal ethical approval. All sources were appropriately cited in accordance with copyright and academic integrity standards.

Results

Study Selection Process

Figure 1 presents the PRISMA flow diagram detailing the systematic identification and screening of articles. Our comprehensive search across five electronic databases initially yielded 1,133 records. After duplicate removal and application of inclusion and exclusion criteria, 697 full-text articles underwent rigorous eligibility assessment. Ultimately, 73 studies met all criteria for inclusion in both the qualitative synthesis and meta-analysis (Appendix 2).

Characteristics of Included Studies

The incorporated studies exhibited the following key characteristics: (1) studies covered nearly all regions of the world, i.e., the Americas, Asia, Europe, and Africa; (2) all studies were conducted between 1999 and 2024; (3) clinical samples consisted of stool specimens from humans. Furthermore, the primary focus was on bacterial pathogens. Detection methods such as conventional disk diffusion, PCR, and ELISA are summarized in Table 2 and Appendix 3.

Table 2. Distribution of global protozoan isolates from 1999-2024.

Source: References [26-85]

Author	Publication Year	Country	Continent	Detection methods	Sample size	Pathogen isolates	Protozoan isolates
Shrestha et al. A [26]	2022	Nepal	Asia	Culture	1,200	1,254	119
Shrestha et al. B [26]	2022	Nepal	Asia	ELISA/PCR	1,200	799	211
Farfán-García et al. A [27]	2020	Colombia	America	ELISA/PCR	431	547	117
Farfán-García et al. B [27]	2020	Colombia	America	Culture	430	346	111
Albert et al. A [28]	1999	Bangladesh	Asia	Culture	814	992	23
Albert et al. B [28]	1999	Bangladesh	Asia	ELISA/Culture	814	479	27
Verma et al. [29]	2019	India (North)	Asia	Culture/PCR	100	73	5
Huhulescu et al. [30]	2009	Austria	Europe	PCR	306	75	4
Aktaş et al. [31]	2019	Turkey	Europe	ELISA/PCR	375	265	2
Tam et al. A [32]	2012	England	Europe	Culture/PCR/Microscopy	874	784	21
Tam et al. B [32]	2012	England	Europe	PCR	782	479	23
Hawash et al. [33]	2017	Saudi Arabia	Asia	ELISA/PCR	163	107	45
Youssef et al. [34]	2000	Jordan	Asia	ELISA/PCR	265	217	19
Williams et al. [35]	2020	Democratic Republic of the Congo	Africa	Culture/PCR/Microscopy	269	391	74
Chopra et al. [36]	2013	India	Asia	ELISA/PCR	200	119	55
Ng’ang’a et al. [37]	2018	Kenya	Africa	Culture/PCR/Microscopy	174	207	1
Ajjampur et al. [38]	2009	India	Asia	PCR	452	114	17
Al-Gallas et al. A [39]	2007	Tunisia	Africa	PCR	271	217	2
Al-Gallas et al. B [39]	2007	Tunisia	Africa	PCR	271	108	2
Torres et al. [40]	2001	Uruguay	America	Culture/PCR	224	215	27
Potgieter et al. [41]	2023	South Africa	Africa	Culture/PCR	275	56	2
Makhari et al. [42]	2012	South Africa	Africa	PCR	2,468	1,081	85
Shrivastava et al. [43]	2017	India	Asia	Culture	130	77	5
Huang et al. A [44]	2018	Taiwan	Asia	PCR	217	87	1
Huang et al. B [44]	2018	Taiwan	Asia	PCR	217	121	1
Zboromyrska et al. [45]	2014	Spain	Europe	ELISA/PCR	185	76	18
Abraham et al. [46]	2024	India	Asia	PCR	2,694	1,812	90
Lanata et al. [47]	2025	Peru	America	PCR	676	945	68
Piralla et al. [48]	2017	Italy	Europe	PCR	168	108	9
Pelkonen et al. A [49]	2018	Angola	Africa	PCR	98	284	31
Pelkonen et al. B [49]	2018	Angola	Africa	PCR	96	166	18
Iqbal et al. [50]	2024	Pakistan	Asia	PCR	245	1,089	137
Alsuwaidi et al. A [51]	2021	UAE	Asia	PCR	203	279	31
Alsuwaidi et al. B [51]	2021	UAE	Asia	ELISA/PCR	73	35	1
Abbasi et al. [52]	2022	Iran	Asia	PCR	211	257	15
Casillas-Verga et al. [53]	2020	Mexico	America	Culture	240	103	12
Jennings et al. [54]	2017	Peru	America	PCR	230	148	16
Eibach et al. A [55]	2016	Ghana	Africa	PCR	443	1,106	262
Eibach et al. B [55]	2016	Ghana	Africa	PCR	239	621	205
Kara et al. [56]	2022	Turkey	Europe	PCR	203	203	7
Khare et al. A [57]	2014	USA	America	PCR	230	91	3
Khare et al. B [57]	2014	USA	America	PCR	230	77	3
Tilmanne et al. A [58]	2019	Belgium	Europe	Culture	178	126	17
Tilmanne et al. B [58]	2019	Belgium	Europe	Culture/PCR	178	78	4
Castany-Feixas et al. [59]	2021	Spain	Europe	PCR	125	88	13
Knee et al. [60]	2018	Mozambique	Africa	PCR	759	183	55
Sameer et al. [61]	2024	Bahrain	Asia	Culture/PCR	109	143	3
Japa et al. [62]	2024	Dominican Republic	America	Culture/PCR	170	227	21
Benmessaoud et al. [63]	2015	Morocco	Africa	PCR	122	123	2
Leli et al. [64]	2020	Italy	Europe	PCR	183	82	2
Buuck et al. [65]	2020	USA	America	PCR	224	242	2
Pativada et al. [66]	2012	India	Asia	PCR	2,535	51	8
Toffel et al. [67]	2019	USA	America	Culture/PCR	222	199	14
Nair et al. [68]	2010	India	Asia	PCR	2,536	2,829	532
Santos et al. [69]	2019	Brazil	America	PCR	591	607	82
Tsagarakis et al. [70]	2017	Greece	Europe	PCR	1,041	2,295	37
Meyer et al. [71]	2022	Switzerland	Europe	PCR	179	134	2
Carmon et al. [72]	2023	Israel	Asia	PCR	91	89	1
Mladenova et al. [73]	2015	Bulgaria	Europe	PCR	92	67	3
Fidalgo et al. [74]	2021	Spain	Europe	Culture/PCR	10,659	1,001	515
McAuliffe et al. [75]	2013	New Zealand	Europe	Culture	1,758	890	130
Holland et al. [76]	2020	United Kingdom	Europe	PCR	566,000	27,879	166
Zizza et al. [77]	2024	Italy	Europe	PCR	103	81	8
Olesen et al. [78]	2005	Denmark	Europe	PCR	424	220	8
Pouletty et al. [79]	2019	France	Europe	PCR	59	181	19
Mihala et al. [80]	2022	Australia	Asia	PCR	154	2,795	57
Nejma et al. A [81]	2014	Tunisia	Africa	PCR	124	296	4
Nejma et al. B [81]	2014	Tunisia	Africa	Culture	54	75	3
Saeed et al. [82]	2019	Libya	Africa	PCR	505	46	30
Brurce et al. A [83]	2016	Central African Republic	Africa	PCR	333	385	50
Brurce et al. B [83]	2016	Central African Republic	Africa	PCR	333	183	41
Murphy et al. [84]	2017	USA	America	PCR	2,257	1,127	48
Albert et al. A [85]	2016	Kuwait	Asia	Culture	109	20	3

Open in a new tab

Forest Plot of Global Protozoan Prevalence

A total of 73 studies involving 59,352 stool samples from patients with diarrhea were included in the meta-analysis. The overall pooled prevalence of protozoa was 7.5% (95% CI: 5.6%-10.0%; logit proportion = 0.075), with significant heterogeneity across studies (I² = 98.4%, p < 0.001) (Figure 2). Subgroup analysis by region showed the highest prevalence in the Americas (12.0%, 95% CI: 6.4%-21.5%; I² = 95.4%), followed by Africa (10.6%, 95% CI: 6.7%-16.5%; I² = 95.3%), Asia (5.6%, 95% CI: 3.6%-8.5%; I² = 97.4%), and Europe (5.6%, 95% CI: 4.1%-7.6%; I² = 96.3%) (Figure 3). The high between-study heterogeneity likely reflects variations in geographic settings, study periods, diagnostic methods, and study populations. Despite this heterogeneity, these findings underscore protozoa as significant contributors to diarrheal disease globally, particularly in the Americas and Africa.

The forest plot was generated using OpenMeta[Analyst] software.

Source: References [26-85].

Funnel plot

The funnel plot analysis revealed that the fail-safe N was extremely high (5,078,779, p < 0.001), indicating strong robustness of the meta-analysis findings against unpublished null studies. The rank correlation test (Kendall’s Tau = −0.249, p < 0.001) suggested possible funnel plot asymmetry and potential publication bias. However, Egger’s regression test showed no significant asymmetry (Z = 0.131, p = 0.896), indicating no evidence of bias. Despite some indication of asymmetry, the high fail-safe N supports the conclusion that the results are stable and unlikely to be substantially affected by missing or unpublished studies (Figure 4).

Subgroup Prevalence of Protozoa in Asia

This meta-analysis evaluated the prevalence of key protozoan pathogens among diarrheal cases in Asia. The most studied pathogen was Cryptosporidium parvum, reported in 19 studies with a pooled prevalence of 46.2% (95% CI: 33.6%-59.3%; I² = 89.74%, p < 0.001), indicating high heterogeneity. Giardia lamblia and Giardia duodenalis were reported in 14 and 13 studies, with prevalences of 52.1% (95% CI: 36.3%-67.9%; I² = 97.08%) and 53.4% (95% CI: 37.6%-68.6%; I² = 91.25%), respectively. Entamoeba histolytica had a lower pooled prevalence of 13.9% (95% CI: 6.3%-27.8%) across 10 studies (I² = 83.08%). Less frequently reported pathogens included Cyclospora cayetanensis (5.0%; 95% CI: 2.4%-10.2%; I² = 54.07%) and Blastocystis hominis (10.5%; 95% CI: 1.8%-42.8%; I² = 95.5%). Isospora was identified in only one study with a prevalence of 21.8% (95% CI: 12.8%-34.6%). Several protozoa were not reported. High heterogeneity suggests geographic and methodological variability across studies (Table 3).

Table 3. Pooled data on the prevalence of protozoan isolates in Asia.

Name of enteric pathogen	No. of studies	Prevalence (%)	95% CI	Heterogeneity test (I²)	p-value
Cyclospora cayetanensis	3	5	2.4-10.2	54.07	0.113
Isospora	1	21.8	12.8-34.6	NA	NA
Giardia lamblia	14	52.1	36.3-67.9	97.08	0
Giardia duodenalis	13	53.4	37.6-68.6	91.25	0
Blastocystis hominis	2	10.5	1.8-42.8	95.5	0
Entamoeba histolytica	10	13.9	6.3-27.8	83.08	0
Endolimax nana	-	-	-	-	-
Entamoeba hartmanni	-	-	-	-	-
Chilomastix mesnili	-	-	-	-	-
Trichomonas hominis	-	-	-	-	-
Cryptosporidium parvum	19	46.2	33.6-59.3	89.74	0

Open in a new tab

Subgroup Prevalence of Protozoa in America

This meta-analysis summarizes protozoan prevalence in diarrheal cases across the Americas. Giardia duodenalis showed the highest pooled prevalence at 56.8% (95% CI: 46.1%-66.9%; I² = 56.63%, p = 0.018), followed closely by Giardia lamblia at 50.3% (95% CI: 19.5%-81.0%; I² = 99.04%, p < 0.001), both highlighting significant contributions to protozoan infections. Cryptosporidium parvum was identified in 13 studies with a pooled prevalence of 29.9% (95% CI: 17.4%-46.3%; I² = 86.38%). Entamoeba histolytica had a prevalence of 25.1% (95% CI: 13.2%-42.4%; I² = 88.11%). Other pathogens with moderate prevalence included Blastocystis hominis (32.4%, 95% CI: 25.4%-40.2%) and Cyclospora cayetanensis (5.0%, 95% CI: 2.4%-16.0%). Rare protozoa such as Entamoeba hartmanni, Endolimax nana, Chilomastix mesnili, and Trichomonas hominis showed consistently low prevalence (2.0-2.6%) with no heterogeneity (I² = 0%). Variability in heterogeneity indicates differences in diagnostic practices and regional burden (Table 4).

Table 4. Pooled data on the prevalence of protozoan isolates in the Americas.

Name of enteric pathogen	No. of studies	Prevalence (%)	95% CI	Heterogeneity test (I²)	p-value
Cyclospora cayetanensis	2	5	2.4-16.0	0	0.905
Isospora	1	3.9	1.0-14.3	0	0.463
Giardia lamblia	14	50.3	19.5-81.0	99.04	0
Giardia duodenalis	9	56.8	46.1-66.9	56.63	0.018
Blastocystis hominis	3	32.4	25.4-40.2	23.88	0.269
Entamoeba histolytica	5	25.1	13.2-42.4	88.11	0
Endolimax nana	2	2.6	1.2-5.7	0	0.948
Entamoeba hartmanni	2	2	0.7-5.1	0	0.361
Chilomastix mesnili	2	2	0.7-5.3	1.3	0.314
Trichomonas hominis	2	2	0.7-5.3	1.3	0.314
Cryptosporidium parvum	13	29.9	17.4-46.3	86.38	0

Open in a new tab

Subgroup Prevalence of Protozoa in Europe

In Europe, Giardia lamblia was the most prevalent protozoan pathogen, reported in 9 studies with a pooled prevalence of 54.5% (95% CI: 41.2%-67.8%; I² = 78.71%, p < 0.001). Giardia duodenalis followed closely at 50.4% (95% CI: 39.5%-61.3%) across 11 studies, with low heterogeneity (I² = 17.85%, p = 0.274), indicating consistency across studies. Cryptosporidium parvum was also common (40.3%; 95% CI: 17.4%-68.3%; I² = 94.28%). Entamoeba histolytica had a moderate prevalence of 15.7% (95% CI: 6.2%-34.4%) with high heterogeneity (I² = 80.10%). Blastocystis hominis was less frequently studied but showed a high pooled prevalence of 52.6% (95% CI: 12.7%-89.4%; I² = 84.57%). Rare protozoa such as Chilomastix mesnili and Trichomonas hominis were each reported in a single study, both with 50.0% prevalence (95% CI: 5.9%-94.1%). No data were available for Cyclospora, Isospora, Endolimax nana, and Entamoeba hartmanni (Table 5).

Table 5. Pooled data on the prevalence of protozoan isolates in Europe.

Name of enteric pathogen	No. of studies	Prevalence (%)	95% CI	Heterogeneity test (I²)	p-value
Cyclospora cayetanensis	-	-	-	-	-
Isospora	-	-	-	-	-
Giardia lamblia	9	54.5	41.2-67.8	78.71	0
Giardia duodenalis	11	50.4	39.5-61.3	17.85	0.274
Blastocystis hominis	2	52.6	12.7-89.4	84.57	0.011
Entamoeba histolytica	7	15.7	6.2-34.4	80.1	0
Endolimax nana	-	-	-	-	-
Entamoeba hartmanni	-	-	-	-	-
Chilomastix mesnili	1	50	5.9-94.1	NA	NA
Trichomonas hominis	1	50	5.9-94.1	NA	NA
Cryptosporidium parvum	17	40.3	17.4-68.3	94.28	0

Open in a new tab

Subgroup Prevalence of Protozoa in Africa

In Africa, Giardia duodenalis had the highest pooled prevalence among protozoan pathogens at 76.4% (95% CI: 57.8%-88.4%; I² = 89.35%, p < 0.001), followed by Giardia lamblia at 58.8% (95% CI: 37.6%-79.9%; I² = 97.82%). Cryptosporidium parvum was also common, with a prevalence of 47.4% (95% CI: 28.4%-67.2%; I² = 92.48%). In contrast, Entamoeba histolytica showed a lower pooled prevalence of 4.7% (95% CI: 1.6%-13.3%; I² = 77.24%). Less prevalent species included Blastocystis hominis (10.6%; 95% CI: 2.8%-33.0%) and Entamoeba hartmanni (14.4%; 95% CI: 2.0%-58.4%). Rare isolates such as Endolimax nana (56.5%) and Trichomonas hominis (50.0%) were reported in limited studies with wide CIs. No data were available for Cyclospora, Isospora, or Chilomastix mesnili in African studies (Table 6).

Table 6. Pooled data on the prevalence of protozoan isolates in Africa.

Name of organism	No. of studies	Prevalence (%)	95% CI	Heterogeneity test (I²)	p-value
Cyclospora cayetanensis	-	-	-	-	-
Isospora	-	-	-	-	-
Giardia lamblia	12	58.8	37.6-79.9	97.82	0
Giardia duodenalis	8	76.4	57.8-88.4	89.35	0
Blastocystis hominis	2	10.6	2.8-33.0	21.24	0
Entamoeba histolytica	7	4.7	1.6-13.3	77.24	0
Endolimax nana	2	56.5	12.3-92.3	26.44	0.244
Entamoeba hartmanni	2	14.4	2.0-58.4	0	0.876
Chilomastix mesnili	-	-	-	-	-
Trichomonas hominis	1	50	5.9-94.1	NA	NA
Cryptosporidium parvum	12	47.4	28.4-67.2	92.48	0

Open in a new tab

Global Pooled Prevalence of Protozoan Diarrheal Pathogens

This meta-analysis synthesized data from multiple studies to estimate the global prevalence of protozoan pathogens in diarrheal cases. Giardia duodenalis had the highest pooled prevalence at 58.6% (95% CI: 50.8%-66.1%; I² = 84.87%, p < 0.001), followed by Giardia lamblia at 53.4% (95% CI: 42.5%-64.2%; I² = 98.15%). Cryptosporidium parvum was also prevalent, detected in 61 studies with a pooled estimate of 41.3% (95% CI: 33.1%-50.0%; I² = 91.31%). Entamoeba histolytica showed a moderate prevalence of 13.1% (95% CI: 8.7%-19.2%). Less common protozoa included Blastocystis hominis (21.4%), Endolimax nana (11.5%), Chilomastix mesnili (5.7%), and Trichomonas hominis (8.9%), all with high heterogeneity. Cyclospora cayetanensis and Isospora were rare, with prevalence rates of 5.6% and 7.7%, respectively (Table 7). High heterogeneity in most estimates reflects study variability across regions and methodologies.

Table 7. Total pooled prevalence estimates for global protozoan isolates.

Name of enteric pathogen	No. of studies	Prevalence (%)	95% CI	Heterogeneity test (I²)	p-value
Cyclospora cayetanensis	5	5.6	3.6-8.6	10.25	0.348
Isospora	3	7.7	1.8-27.2	59.76	0.059
Giardia lamblia	49	53.4	42.5-64.2	98.15	0
Giardia duodenalis	41	58.6	50.8-66.1	84.87	0
Blastocystis hominis	9	21.4	8.5-44.3	97.27	0
Entamoeba histolytica	29	13.1	8.7-19.2	87.2	0
Endolimax nana	4	11.5	2.0-45.5	79.43	0.002
Entamoeba hartmanni	4	3.1	1.0-9.4	25.49	0.259
Chilomastix mesnili	3	5.7	1.0-27.1	66.53	0.03
Trichomonas hominis	4	8.9	1.1-44.4	76.93	0.005
Cryptosporidium parvum	61	41.3	33.1-50.0	91.31	0

Open in a new tab

Subgroup Prevalence of Global Protozoan Detections Using Various Diagnotics Methods

The forest plot presents a comprehensive meta-analysis of multiple studies investigating protozoan detection using various diagnostic methods. The studies are grouped according to the detection technique employed, including PCR, ELISA/Culture, Culture/PCR/Microscopy, Culture/PCR, and Culture alone. Each study is represented with its name, the proportion of positive protozoan detection (referred to as the estimate), the 95% CI, and the number of positive cases over the total examined (Figure 5).

Among the subgroups, studies using PCR exhibited the highest pooled proportion of protozoan detection at 60.9% (95% CI: 49.2%-72.6%), though heterogeneity was extremely high (I² = 99.9%), suggesting substantial variability between studies. The ELISA/Culture subgroup showed a lower pooled detection rate of 50.2% (95% CI: 17.1%-79.2%), again with significant heterogeneity (I² = 99.9%). Similarly, pooled detection rates for the Culture/PCR/Microscopy and Culture/PCR subgroups were 51.4% and 56.7%, respectively. The Culture-only subgroup yielded a pooled detection rate of 60.9% (95% CI: 29.6%-90.4%).

The overall analysis, which combined all included studies regardless of detection method, resulted in a pooled protozoan detection proportion of 59.2% (95% CI: 48.6%-69.8%). However, overall heterogeneity was very high (I² = 99.98%), indicating considerable differences across studies that may stem from varying sample sizes, populations, methodologies, and laboratory techniques.

Similarly, the forest plot displays a meta-analysis of protozoan prevalence across multiple studies, grouped by year. Each study’s logit proportion and CI are shown, with subgroup and overall pooled estimates highlighted. The overall prevalence estimate was 0.613 (95% CI: 0.543-0.680), with significant heterogeneity (I² = 99.43%). Most subgroups also demonstrated high heterogeneity (I² > 90%), suggesting variability in protozoan prevalence across studies and years (Figure 6).

Meta-Regression Analysis

The meta-regression analyses examining protein-related factors (Tprot) and temporal trends (Year) demonstrated consistent null findings with persistent heterogeneity. For the Tprot analysis, results showed no significant association with effect sizes (β = -0.000, p = 0.533), while revealing substantial residual heterogeneity (I² = 98.62%) that remained unexplained (R² = 0%). The significant intercept (0.116, p = 0.002) indicated baseline effects independent of protein factors. Similarly, the Year analysis found no temporal relationship (β = -0.001, p = 0.868), with nearly identical heterogeneity levels (I² = 98.64%) and no explained variance. The non-significant intercept (p = 0.861) further confirmed the absence of meaningful temporal patterns. Below is a map showing the distribution of global protozoan isolates across continents (Figures 7-9).

Meta-regression analysis was performed using OpenMEE software.

The map was generated using MapChart software.

Discussion

The global prevalence of enteric protozoa varies considerably across regions, largely influenced by disparities in sanitation, water quality, and socioeconomic conditions [86,87]. Protozoan pathogens such as Cyclospora cayetanensis, Isospora, and Giardia duodenalis pose significant public health risks, particularly in low- and middle-income countries [87].

A recent systematic review estimated that Cyclospora cayetanensis is more common in Africa than in other regions, especially in low-income settings [88]. In South America, its prevalence is elevated among individuals living with HIV/AIDS, while the lowest levels are observed in Asia [89]. Environmental factors such as seasonal rainfall and temperature influence transmission, with considerable levels of water contamination reported in endemic areas [90]. Although Cyclospora cayetanensis typically causes localized outbreaks, it remains a notable public health concern in Latin America and among children in South Asia [91]. Transmission through contaminated produce and seasonal variability underscores the urgent need for improved food safety in endemic regions. Coincidentally, Entamoeba histolytica also remains widespread in South Asia and sub-Saharan Africa [92]. However, our systematic review and meta-analysis found comparable Cyclospora cayetanensis prevalence in both Asia and the Americas.

Further, Giardia duodenalis continues to be one of the most widespread protozoan pathogens globally, accounting for a substantial number of symptomatic cases each year [93]. Its burden is greatest among children in developing regions, where prevalence rates are significantly higher than in high-income countries [94]. For instance, a Brazilian study identified notable levels of Giardia infection, frequently co-occurring with Blastocystis hominis [95,96]. Entamoeba histolytica also contributes substantially to gastrointestinal morbidity, particularly among travelers and individuals in endemic areas [97]. The present meta-analysis found that Giardia duodenalis is prevalent in Asia, the Americas, Africa, and Europe, while Entamoeba histolytica was also commonly detected in these regions, though with variable distribution.

Other protozoan pathogens, including Blastocystis hominis and Cryptosporidium parvum, exhibit distinct regional patterns. For instance, in sub-Saharan Africa and South Asia, Blastocystis hominis is frequently found among children [98-100]. Cryptosporidium parvum also demonstrates concerning trends, especially among African children and individuals with compromised immune systems. Furthermore, recent studies have highlighted the prevalence and molecular identification of Entamoeba histolytica, Giardia intestinalis, and Cryptosporidium parvum in pediatric gastroenteritis, as well as advances in the detection and epidemiology of Cyclospora cayetanensis, underscoring their persistent public health importance [101-103]. Blastocystis hominis further demonstrates widespread colonization, especially in Southeast Asia and the Middle East [104,105]. Although its pathogenicity remains under debate, growing associations with irritable bowel syndrome and chronic gastrointestinal symptoms warrant additional investigation. These trends highlight the resilience of protozoa in impoverished environments and their disproportionate impact on vulnerable populations. Our study indicated that Blastocystis hominis is widespread across all continents, with the highest rates observed in Europe, while Cryptosporidium parvum was similarly distributed, with particularly high occurrence in Asia and Africa.

Less frequently studied protozoa such as Endolimax nana, Entamoeba hartmanni, and Chilomastix mesnili have been identified in Africa and South Asia, often as indicators of fecal contamination and substandard hygiene [106]. Though generally nonpathogenic, their presence signals environmental exposure to unsanitary conditions. For example, Endolimax nana, which closely resembles Entamoeba histolytica morphologically, can be misidentified and is transmitted through the fecal-oral route. Asymptomatic carriers can contribute significantly to environmental contamination, thereby sustaining transmission cycles in affected communities [106-109]. Our review found that Endolimax nana and Entamoeba hartmanni are more common in Africa than in the Americas, while Chilomastix mesnili showed a particularly high occurrence in African settings.

Supporting these findings, our meta-analysis of 73 studies involving over 59,000 diarrheal cases revealed that protozoan infections are globally widespread, with the highest burden reported in the Americas and Africa. Giardia duodenalis, Giardia lamblia, and Cryptosporidium parvum were consistently the most frequently identified species across regions. Although considerable variability existed among studies (I² > 90%), the findings were statistically robust, with minimal publication bias. Diagnostic methods played a critical role in detection, with molecular approaches such as PCR yielding higher prevalence estimates. Meta-regression analysis found no significant link with time trends or protein-related variables, reinforcing the persistent nature of protozoan infections. These results underscore the pressing need for integrated public health strategies that enhance diagnostics, establish routine surveillance, and prioritize sustained investment in water, sanitation, and hygiene (WASH) infrastructure to effectively combat the enduring burden of enteric protozoa globally.

This study’s limitations include high heterogeneity, diagnostic variability, and data gaps from low-resource regions. Most data were cross-sectional and lacked standardized protocols. Future research should employ molecular diagnostics, conduct longitudinal studies, and explore asymptomatic transmission and co-infections. Improved surveillance and WASH interventions are essential to reduce the global burden of enteric protozoan infections.

Conclusions

This review highlights the significant global burden of enteric protozoan infections, particularly in low- and middle-income regions. The findings underscore the urgent need for improved diagnostics, routine surveillance, and strengthened WASH infrastructure. Addressing these challenges through integrated public health strategies is essential to reduce transmission, improve health outcomes, and protect vulnerable populations from protozoa-related gastrointestinal illnesses worldwide.

Acknowledgments

The authors gratefully acknowledge Universiti Sains Malaysia (USM) for the Postdoctoral Fellowship and TETFund (Nigeria) for the Postdoctoral Fellowship Scholarship Award.

Appendices

Appendix 1

The quality of the 73 included studies was assessed based on the following criteria: (1) appropriate sampling frame to address the target population, (2) appropriate method of sampling study participants, (3) adequate sample size, (4) detailed description of study participants and settings, (5) data analysis with sufficient coverage of the identified sample, (6) use of valid methods to identify the condition, (7) standard and reliable measurement of the condition for all participants, (8) availability of appropriate statistical analysis, and (9) adequate response rate with proper management of low response rates. The quality of the included studies was evaluated using the JBI critical appraisal checklist for studies reporting prevalence data.

Table 8. Quality of included studies by JBI critical appraisal checklist for studies reporting prevalence data.

References [26-85]

Study name		Checklist*									Overall
Study name		1	2	3	4	5	6	7	8	9
1	Shrestha et al.A [26]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
2	Shrestha et al.B [26]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
3	Farfán-García et al.A [27]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
4	Farfán-García et al.B [27]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
5	Albert et al.A [28]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
6	Albert et al.B [28]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
7	Verma et al. [29]	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	8
8	Huhulescu et al. [30]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
9	Aktaş et al. [31]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	8
10	Tam et al.A [32]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
11	Tam et al.B [32]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
12	Hawash et al. [33]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
13	Youssef et al. [34]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
14	Williams et al. [35]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
15	chopra et al. [36]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
16	Ng’ang’a et al. [37]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
17	Ajjampur et al. [38]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
18	Al-Gallas et al.A [39]	Yes	No	Yes	NO	Yes	Yes	Yes	Yes	Yes	7
19	Al-Gallas et al.B [39]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
20	Torres et al. [40]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
21	Potgieter et al. [41]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
22	Makhari et al. [42]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
23	Shrivastava et al. [43]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
24	Huang et al.A [44]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
25	Huang et al.B [44]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
26	Zboromyrska et al. [45]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
27	Abraham et al. [46]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
28	Lanata et al. [47]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
29	Piralla et al. [48]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
30	Pelkonen et al.A [49]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
31	Pelkonen et al.B [49]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
32	Iqbal et al. [50]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
33	Alsuwaidi et al.A [51]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
34	Alsuwaidi et al.B [51]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
35	Abbasi et al. [52]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
36	Casillas-Verga et al. [53]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
37	Jennings et al. [54]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
38	Eibach et al.A [55]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
39	Eibach et al.B [55]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
40	Kara et al. [56]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
41	Khare et al.A [57]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
42	Khare et al.B [57]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
43	Tilmanne et al.A [58]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
44	Tilmanne et al.B [58]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
45	Castany-Feixas et al. [59]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
46	Knee et al. [60]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
47	Sameer et al. [61]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
48	Japa et al. [62]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
49	Benmessaoud et al. [63]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
50	Leli et al. [64]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
51	Buuck et al. [65]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
52	Pativada et al. [66]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
53	Toffel et al. [67]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
54	Nair et al. [68]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
55	Santos et al. [69]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
56	Tsagarakis et al. [70]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
57	Meyer et al. [71]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7
58	Carmon et al. [72]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
59	Mladenova et.al [73]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	9
60	Fidalgo et al. [74]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
61	McAuliffe et al. [75]	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	8
62	Holland et al. [76]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
63	Zizza et al. [77]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	8
64	Olesen et al. [78]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
65	Pouletty et al. [79]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
66	Mihala et al. [80]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
67	Nejma et al.A [81]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
68	Nejma et al.B [81]	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes	7
69	Saaed et al. [82]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
70	Brurec et al.A [83]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
71	Brurec et al.B [83]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
72	Murphy et al. [84]	Yes	No	Yes	NO	Yes	Yes	Yes	Yes	Yes	7
73	Albertt et al.A [85]	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes	7

Open in a new tab

Appendix 2

Search Strategy Word (Dec 30, 2024). Total Search = 1133

Web of Science (N = 164) (Dec 30, 2024)

https://www.webofscience.com/wos/alldb/summary/9cc2ac32-4cb4-423e-8197-6e88b24ca0c4-0144be2588/relevance/1

(((((((((((((((((((((((((((((((((((ALL=(Coinfection)) OR ALL=(Concurrent infection)) OR ALL=(Dual infection)) AND ALL=(Prevalence)) OR ALL=(Incidence)) OR ALL=(Occurrence)) AND ALL=(Cholera)) OR ALL=(Vibrio cholerae)) OR ALL=(V. cholerae)) OR ALL=(Vibrio cholerae infection)) OR ALL=(Cholera disease)) OR ALL=(Cholera outbreaks)) OR ALL=(Cholera epidemic)) AND ALL=(Shigella)) OR ALL=(Shigellosis)) OR ALL=(Shigella-induced diarrhea)) OR ALL=(Shigella enteric infection)) AND ALL=(Escherichia coli)) OR ALL=(E. coli infection)) OR ALL=(Pathogenic E. coli)) OR ALL=(Enteropathogenic E. coli)) AND ALL=(Campylobacter)) OR ALL=(Campylobacter infection)) OR ALL=(Campylobacteriosis)) OR ALL=(Campylobacter enteric infection)) AND ALL=(Rotavirus)) OR ALL=(Rotavirus infection)) OR ALL=(Rotaviral gastroenteritis)) OR ALL=(Rotavirus-induced diarrhea)) AND ALL=(Norovirus)) OR ALL=(Norovirus infection)) OR ALL=(Noroviral gastroenteritis)) OR ALL=(Norovirus-induced diarrhea)) AND ALL=(Cryptosporidium)) OR ALL=(Cryptosporidiosis)) AND ALL=(Salmonella)

PubMed (N = 9) (Dec 30, 2024) (Coinfection[Title/Abstract]) OR (Co-infection[Title/Abstract]) AND (Prevalence[Title/Abstract]) OR (Incidence[Title/Abstract]) AND (Cholera[Title/Abstract]) OR (Vibrio cholera[Title/Abstract]) OR (V. cholera[Title/Abstract]) AND (Shigella[Title/Abstract]) OR (Shigellosis[Title/Abstract]) AND (Escherichia coli[Title/Abstract]) OR (E. coli[Title/Abstract]) AND (Campylobacter[Title/Abstract]) AND (Rotavirus[Title/Abstract]) AND (Norovirus[Title/Abstract]) AND (Cryptosporidium[Title/Abstract])

PubMed (N = 17) (Dec 30, 2024) - MeSH Combination "Coinfection"[Mesh] OR "Coinfection/microbiology"[Mesh] OR "Coinfection/parasitology"[Mesh] OR "Coinfection/prevention and control"[Mesh] OR "Coinfection/virology"[Mesh] OR "Prevalence"[Mesh] AND "Epidemiology"[Mesh] AND "epidemiology"[Subheading] OR "Incidence"[Mesh] AND "Epidemiology"[Mesh] AND "epidemiology"[Subheading] AND "Cohort Studies"[Mesh] OR "Cholera"[Mesh] AND "Vibrio cholerae"[Mesh] AND "Cholera Vaccines"[Mesh] OR "Shigella"[Mesh] AND "Shigella dysenteriae"[Mesh] AND "Shigella Vaccines"[Mesh] OR ("Dysentery, Bacillary/microbiology"[Mesh] OR "Dysentery, Bacillary/parasitology"[Mesh] OR "Dysentery, Bacillary/prevention and control"[Mesh] OR "Dysentery, Bacillary/virology"[Mesh]) OR "Escherichia coli"[Mesh] AND "Escherichia coli Vaccines"[Mesh] OR "Rotavirus"[Mesh] AND "Rotavirus Vaccines"[Mesh] AND "Rotavirus Infections"[Mesh] OR "Campylobacter"[Mesh] AND "Campylobacter Infections"[Mesh] OR "Norovirus"[Mesh] AND "Caliciviridae Infections"[Mesh] AND "Salmonella"[Mesh]

Scopus Format (N = 39) (Dec 30, 2024) TITLE-ABS ((coinfection OR "Co-infection" OR "Concurrent infection" OR "Dual infection" ) AND ( prevalence OR incidence OR occurrence ) AND ( cholera OR "Vibrio cholerae" OR "V. cholerae" OR "Vibrio cholerae infection" OR "Cholera disease" OR "Cholera outbreaks" OR "Cholera epidemic" ) AND ( shigella OR shigellosis OR "Shigella-induced diarrhea" OR "Shigella enteric infection" ) AND ( "Escherichia coli" OR "E. coli infection" OR "Pathogenic E. coli" OR "Enteropathogenic E. coli" ) AND ( campylobacter OR "Campylobacter infection" OR campylobacteriosis OR "Campylobacter enteric infection" ) AND ( rotavirus OR "Rotavirus infection" OR "Rotaviral gastroenteritis" OR "Rotavirus-induced diarrhea" ) AND ( norovirus OR "Norovirus infection" OR "Noroviral gastroenteritis" OR "Norovirus-induced diarrhea" ) AND ( cryptosporidium OR "Cryptosporidium infection" OR cryptosporidiosis ) AND salmonella)

Google Scholar (N = 785) (Dec 30, 2024) allintitle: ( ( coinfection OR "Co-infection" OR "Concurrent infection" OR "Dual infection" ) AND ( prevalence OR incidence OR occurrence ) AND ( cholera OR "Vibrio cholerae" OR "V. cholerae" OR "Vibrio cholerae infection" OR "Cholera disease" OR "Cholera outbreaks" OR "Cholera epidemic" ) AND ( shigella OR shigellosis OR "Shigella-induced diarrhea" OR "Shigella enteric infection" ) AND ( "Escherichia coli" OR "E. coli infection" OR "Pathogenic E. coli" OR "Enteropathogenic E. coli" ) AND ( campylobacter OR "Campylobacter infection" OR campylobacteriosis OR "Campylobacter enteric infection" ) AND ( rotavirus OR "Rotavirus infection" OR "Rotaviral gastroenteritis" OR "Rotavirus-induced diarrhea" ) AND ( norovirus OR "Norovirus infection" OR "Noroviral gastroenteritis" OR "Norovirus-induced diarrhea" ) AND ( cryptosporidium OR "Cryptosporidium infection" OR cryptosporidiosis ) AND salmonella )

Science Direct (N = 128) (Dec 30, 2024) - Search by Title, Abstract, or Author-Specified Keywords ("Coinfection" OR "Co-infection") ("Prevalence" OR "Incidence") ("Cholera" OR "Vibrio cholera" OR "V. cholera") ("Shigella" OR "Shigellosis") ("Escherichia coli" OR "E. coli infection") ("Campylobacter") ("Rotavirus") ("Norovirus") ("Cryptosporidium") ("Salmonella")

Appendix 3

Table 9. Distribution of various protozoan species in diarrhea cases from 1999-2024.

Source: References [26-85].

S/N	Author	Publication Year	Country	Continent	Case sample size	Total pathogens	Total protozoan	Cyclospora cayetanensis	Isospora	Giardia lamblia	Giardia duodenalis	Blastocystis hominis	Entamoeba histolytica	Endolimax nana	Entamoeba hartmanni	Chilomastix mesnili	Trichomonas hominis	Morganella morganii	Cryptosporidium parvum
1	Shrestha et al. A [26]	2022	Nepal	Asia	1200	1254	119	10	0	83	0	0	0	0	0	0	0	0	26
2	Shrestha et al. B [26]	2022	Nepal	Asia	1200	799	211	8	0	193	0	0	0	0	0	0	0	0	10
3	Farfán-García et al. A [27]	2020	Colombia	America	431	547	117	0	0	0	24	43	31	3	3	1	0	0	12
4	Farfán-García et al. B [27]	2020	Colombia	America	430	346	111	0	0	0	25	33	43	3	1	3	0	0	3
5	Albert et al. A [28]	1999	Bangladesh	Asia	814	992	23	0	0	7	0	0	5	0	0	0	0	0	11
6	Albert et al. B [28]	1999	Bangladesh	Asia	814	479	27	0	0	23	0	0	1	0	0	0	0	0	3
7	Verma et al. [29]	2019	India (North)	Asia	100	73	5	0	0	0	4	0	1	0	0	0	0	0	0
8	Huhulescu et al. [30]	2009	Austria	Europe	306	75	4	0	0	2	0	0	0	0	0	0	0	0	2
9	Aktaş et al. [31]	2019	Turkey	Europe	375	265	2	0	0	0	0	0	0	0	0	1	1	0	0
10	Tam et al. A [32]	2012	England	Europe	874	784	21	0	0	9	0	0	0	0	0	0	0	0	12
11	Tam et al. B [32]	2012	England	Europe	782	479	23	0	0	15	0	0	0	0	0	0	0	0	8
12	Hawash et al. [33]	2017	Saudi Arabia	Asia	163	107	45	0	0	0	27	0	4	0	0	0	0	0	14
13	Youssef et al. [34]	2000	Jordan	Asia	265	217	19	0	0	2	0	0	13	0	0	0	0	0	4
14	Williams et al. [35]	2020	Democratic Republic of the Congo	Africa	269	391	74	0	0	0	0	0	0	0	0	0	0	0	74
15	Chopra et al. [36]	2013	India	Asia	200	119	55	1	12	0	0	0	0	0	0	0	0	0	42
16	Ng’ang’a et al. [37]	2018	Kenya	Africa	174	207	1	0	0	0	0	0	0	0	0	0	0	1	0
17	Ajjampur et al. [38]	2009	India	Asia	452	114	17	0	0	0	0	0	0	0	0	0	0	0	17
18	Al-Gallas et al. A [39]	2007	Tunisia	Africa	271	217	2	0	0	2	0	0	0	0	0	0	0	0	0
19	Al-Gallas et al. B [39]	2007	Tunisia	Africa	271	108	2	0	0	0	0	0	0	2	0	0	0	0	0
20	Torres et al. [40]	2001	Uruguay	America	224	215	27	0	0	8	0	0	0	0	0	0	0	0	19

Open in a new tab

Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design: Joseph B. Suleiman, Maryam Azlan

Acquisition, analysis, or interpretation of data: Joseph B. Suleiman

Drafting of the manuscript: Joseph B. Suleiman

Critical review of the manuscript for important intellectual content: Joseph B. Suleiman, Maryam Azlan

Supervision: Maryam Azlan

References

1.Meki DC. South Africa: University of Pretoria; 2023. Framework for mitigating the risk of waterborne diarrheal diseases in peri-urban areas of Lusaka district Zambia [PhD Thesis] [Google Scholar]
2.Review on emerging waterborne pathogens in Africa: the case of Cryptosporidium. Kombo Mpindou GM, Bueno IE, Ramón EC. Water. 2021;13:2966. [Google Scholar]
3.Challenge of diagnosing acute infections in poor resource settings in Africa. Chidzwondo F, Mutapi F. AAS Open Res. 2024;4:28. [Google Scholar]
4.Global, regional, and national age-sex-specific burden of diarrhoeal diseases, their risk factors, and aetiologies, 1990-2021, for 204 countries and territories: a systematic analysis for the Global Burden of Disease Study 2021. GBD 2021 Diarrhoeal Diseases Collaborators. Lancet Infect Dis. 2025;25:519–536. doi: 10.1016/S1473-3099(24)00691-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Global, regional, and national age-sex-specific burden of diarrhoeal diseases, their risk factors, and aetiologies, 1990-2021, for 204 countries and territories: a systematic analysis for the Global Burden of Disease Study. Kyu HH, Vongpradith A, Dominguez R-MV, et al. https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(24)00691-1.pdf. Lancet Infect Dis. 2025;25:519–556. doi: 10.1016/S1473-3099(24)00691-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Global burden of diarrhea disease in the older adult and its attributable risk factors from 1990 to 2021: a comprehensive analysis from the global burden of disease study 2021. Zhao WZ, Wang JY, Zhang MN, Wu SN, Dai WJ, Yang XZ, Wang HG. Front Public Health. 2025;13:1541492. doi: 10.3389/fpubh.2025.1541492. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Acute lower respiratory infections among children under five in Sub-Saharan Africa: a scoping review of prevalence and risk factors. Sarfo JO, Amoadu M, Gyan TB, et al. BMC Pediatr. 2023;23:225. doi: 10.1186/s12887-023-04033-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): an umbrella review. Besnier E, Thomson K, Stonkute D, et al. PLoS One. 2021;16:0. doi: 10.1371/journal.pone.0251905. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Baral B, Mamale K, Gairola S, Chauhan C, Dey A, Kaundal RK. Nanostructured Drug Delivery Systems in Infectious Disease Treatment. Amsterdam, Netherland: Elsevier; 2024. Infectious diseases and its global epidemiology; pp. 1–24. [Google Scholar]
10.Use-case scenarios for an anti-Cryptosporidium therapeutic. Ashigbie PG, Shepherd S, Steiner KL, et al. PLoS Negl Trop Dis. 2021;15:0. doi: 10.1371/journal.pntd.0009057. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Prevalence of Cryptosporidium and Giardia infections in under-five children with diarrhoea in Blantyre, Malawi. Bitilinyu-Bangoh JE, Riesebosch S, Rebel M, Chiwaya P, Verschoor SP, Voskuijl WP, Schallig HD. BMC Infect Dis. 2024;24:68. doi: 10.1186/s12879-024-08979-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Clinical significance of respiratory involvement in Cryptosporidiosis: cross-sectional study of children with diarrhea and respiratory symptoms in Uganda. Mor SM, Ndeezi G, Ascolillo LR, et al. Am J Trop Med Hyg. 2024;111:796–803. doi: 10.4269/ajtmh.24-0112. [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Cryptosporidiosis in a zoonotic gastrointestinal disorder perspective: present status, risk factors, pathophysiology, and treatment, particularly in immunocompromised patients. Balendran T, Iddawela D, Lenadora S. J Trop Med. 2024;2024:6439375. doi: 10.1155/2024/6439375. [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Giardia duodenalis in human health: a comprehensive review of its epidemiology, transmission, pathophysiology, diagnostics, and control strategies. Barasa E, Indusa W, Were T. AEJI. 2025;15:109–126. [Google Scholar]
15.Geboes K, Jouret‐Mourin A. Morson and Dawson's Gastrointestinal Pathology. New Jersey, US: Wiley; 2024. Inflammatory disorders of the small intestine ; pp. 397–461. [Google Scholar]
16.Food and drinking water as sources of pathogenic protozoans: an update. Rossi F, Santonicola S, Amadoro C, Marino L, Colavita G. Appl Sci. 2024;14:5339. [Google Scholar]
17.Upadhyay SK, Singh M, Sharma AK. New Developments in Medical Research. New York, US: Nova Science Publishers Inc; 2024. Therapeutic advances in human health and diseases. [Google Scholar]
18.The association between climatic factors and waterborne infectious outbreaks with a focus on vulnerability in Pakistan: integrative review. Sharif F, Shahzad L, Batool M. Int J Environ Health Res. 2024;34:3299–3316. doi: 10.1080/09603123.2024.2302040. [DOI] [PubMed] [Google Scholar]
19.Utami WS. Intestinal Parasites - New Developments in Diagnosis, Treatment, Prevention and Future Directions. London, UK: IntechOpen; 2024. Zoonotic risk of Cryptosporidium spp. prevention with One Health approach in Indonesia. [Google Scholar]
20.Reyes R, Ahn R, Thurber K, Burke TF. Insight into Epidemiology. New York, US: Springer; 2024. Urbanization and Infectious Disease Dynamics: Examining the Health Risks of Rapid Urban Growth; pp. 123–146. [Google Scholar]
21.Jasuja JK. Saarbrücken, Germany: Saarländische Universitäts- und Landesbibliothek; 2024. Application of stool-based multiplex real-time PCR for persistent digestive disorders in Mali and Côte d'Ivoire [Dissertation] [Google Scholar]
22.Akinnubi T. Intestinal Parasites - New Developments in Diagnosis, Treatment, Prevention and Future Directions. London, UK: IntechOpen; 2024. Cryptosporidium spp.: challenges in control and potential therapeutic strategies; pp. 91–107. [Google Scholar]
23.Muyyarikkandy MS, Kniel K, Bower WA, Vieira AR, Negrón ME, Thakur S. Modernizing Global Health Security to Prevent, Detect, and Respond. Amsterdam, Netherlands: Elsevier; 2024. Assessment of critical gaps in prevention, control, and response to major bacterial, viral, and protozoal infectious diseases at the human, animal, and environmental interface; pp. 175–195. [Google Scholar]
24.Tackling infectious diseases in the Caribbean and South America: epidemiological insights, antibiotic resistance, associated infectious diseases in immunological disorders, global infection response, and experimental anti-idiotypic vaccine candidates against microorganisms of public health importance. Justiz-Vaillant A, Soodeen S, Gopaul D, et al. Microorganisms. 2025;13:282. doi: 10.3390/microorganisms13020282. [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Imam FB, Darmstadt GL, Zaidi AK. Remington and Klein's Infectious Diseases of the Fetus and Newborn E-Book. Amsterdam, Netherlands: Elsevier; 2025. Neonatal infections: a global perspective; pp. 24–53. [Google Scholar]
26.Etiology of acute diarrheal disease and antimicrobial susceptibility pattern in children younger than 5 years old in Nepal. Shrestha SK, Shrestha J, Mason CJ, et al. Am J Trop Med Hyg. 2023;108:174–180. doi: 10.4269/ajtmh.21-1219. [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Etiology of acute gastroenteritis among children less than 5 years of age in Bucaramanga, Colombia: a case-control study. Farfán-García AE, Imdad A, Zhang C, et al. PLoS Negl Trop Dis. 2020;14:0. doi: 10.1371/journal.pntd.0008375. [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Case-control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. Albert MJ, Faruque AS, Faruque SM, Sack RB, Mahalanabis D. J Clin Microbiol. 1999;37:3458–3464. doi: 10.1128/jcm.37.11.3458-3464.1999. [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Etiological agents of diarrhea in hospitalized pediatric patients with special emphasis on diarrheagenic Escherichia coli in North India. Verma S, Venkatesh V, Kumar R, et al. J Lab Physicians. 2019;11:68–74. doi: 10.4103/JLP.JLP_123_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Etiology of acute gastroenteritis in three sentinel general practices, Austria 2007. Huhulescu S, Kiss R, Brettlecker M, Cerny RJ, Hess C, Wewalka G, Allerberger F. Infection. 2009;37:103–108. doi: 10.1007/s15010-008-8106-z. [DOI] [PubMed] [Google Scholar]
31.A molecular study on the prevalence and coinfections of Rotavirus, Norovirus, Astrovirus and Adenovirus in children with gastroenteritis. Aktaş O, Aydin H, Timurkan MO. Minerva Pediatr. 2019;71:431–437. doi: 10.23736/S0026-4946.16.04304-X. [DOI] [PubMed] [Google Scholar]
32.Changes in causes of acute gastroenteritis in the United Kingdom over 15 years: microbiologic findings from 2 prospective, population-based studies of infectious intestinal disease. Tam CC, O'Brien SJ, Tompkins DS, et al. Clin Infect Dis. 2012;54:1275–1286. doi: 10.1093/cid/cis028. [DOI] [PubMed] [Google Scholar]
33.High frequency of enteric protozoan, viral, and bacterial potential pathogens in community-acquired acute diarrheal episodes: evidence based on results of luminex gastrointestinal pathogen panel assay. Hawash YA, Ismail KA, Almehmadi M. Korean J Parasitol. 2017;55:513–521. doi: 10.3347/kjp.2017.55.5.513. [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan. Youssef M, Shurman A, Bougnoux M, Rawashdeh M, Bretagne S, Strockbine N. FEMS Immunol Med Microbiol. 2000;28:257–263. doi: 10.1111/j.1574-695X.2000.tb01485.x. [DOI] [PubMed] [Google Scholar]
35.Prevalence and diversity of enteric pathogens among cholera treatment centre patients with acute diarrhea in Uvira, Democratic Republic of Congo. Williams C, Cumming O, Grignard L, et al. BMC Infect Dis. 2020;20:741. doi: 10.1186/s12879-020-05454-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Descriptive epidemiology of enteric disease in Chennai, India. Chopra RD, Dworkin MS. Epidemiol Infect. 2013;141:953–957. doi: 10.1017/S0950268812001409. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Ng’ang’a GW. JKUAT-COHES. Kenya: Jomo Kenyatta University of Agriculture and Technology; 2018. Bacterial and Parasitic Co-Infections, Antimicrobial Susceptibility and ESBL Genes Carriage in Bacteria Isolated from Children below 5 Years with Diarrhea Attending Mukuru Slum Health Clinics [Master's thesis] [Google Scholar]
38.Giardia duodenalis assemblages associated with diarrhea in children in South India identified by PCR-RFLP. Ajjampur SS, Sankaran P, Kannan A, Sathyakumar K, Sarkar R, Gladstone BP, Kang G. https://pmc.ncbi.nlm.nih.gov/articles/PMC3909731/pdf/nihms545838.pdf. Am J Trop Med Hyg. 2009;80:16–19. [PMC free article] [PubMed] [Google Scholar]
39.Etiology of acute diarrhea in children and adults in Tunis, Tunisia, with emphasis on diarrheagenic Escherichia coli: prevalence, phenotyping, and molecular epidemiology. Al-Gallas N, Bahri O, Bouratbeen A, Haasen AB, Aissa RB. https://riip.hal.science/pasteur-01375250/file/Etiology%20of%20Acute%20Diarrhea.pdf. Am J Trop Med Hyg. 2007;77:571–582. [PubMed] [Google Scholar]
40.Etiology of children's diarrhea in Montevideo, Uruguay: associated pathogens and unusual isolates. Torres ME, Pírez MC, Schelotto F, et al. J Clin Microbiol. 2001;39:2134–2139. doi: 10.1128/JCM.39.6.2134-2139.2001. [DOI] [PMC free article] [PubMed] [Google Scholar]
41.High burden of co-infection with multiple enteric pathogens in children suffering with diarrhoea from rural and peri-urban communities in South Africa. Potgieter N, Heine L, Ngandu JP, et al. Pathogens. 2023;12:315. doi: 10.3390/pathogens12020315. [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Makhari Z. Makhari Z: Characterization of bacterial causes of diarrhoea in an under-five population in South Africa. Johannesburg, South Africa. 2012. https://www.google.com/url?sa=i&url=https%3A%2F%2Ftwas.org%2Fsites%2Fdefault%2Ffiles%2Fcv%2Fcv._prof_shabir_madhi.2022_sam.doc&psig=AOvVaw2zVDTfRn6lqG0gtr4OIm87&ust=1757009697372000&source=images&cd=vfe&opi=89978449&ved=0CAcQr5oMahcKEwjY2rSomb2PAxUAAAAAHQAAAAAQBA https://www.google.com/url?sa=i&url=https%3A%2F%2Ftwas.org%2Fsites%2Fdefault%2Ffiles%2Fcv%2Fcv._prof_shabir_madhi.2022_sam.doc&psig=AOvVaw2zVDTfRn6lqG0gtr4OIm87&ust=1757009697372000&source=images&cd=vfe&opi=89978449&ved=0CAcQr5oMahcKEwjY2rSomb2PAxUAAAAAHQAAAAAQBA
43.Multiple etiologies of infectious diarrhea and concurrent infections in a pediatric outpatient-based screening study in Odisha, India. Shrivastava AK, Kumar S, Mohakud NK, Suar M, Sahu PS. Gut Pathog. 2017;9:1–12. doi: 10.1186/s13099-017-0166-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Detection of common diarrhea-causing pathogens in Northern Taiwan by multiplex polymerase chain reaction. Huang SH, Lin YF, Tsai MH, Yang S, Liao ML, Chao SW, Hwang CC. Medicine (Baltimore) 2018;97:0. doi: 10.1097/MD.0000000000011006. [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Aetiology of traveller's diarrhoea: evaluation of a multiplex PCR tool to detect different enteropathogens. Zboromyrska Y, Hurtado JC, Salvador P, et al. Clin Microbiol Infect. 2014;20:0. doi: 10.1111/1469-0691.12621. [DOI] [PubMed] [Google Scholar]
46.Effect of non-rotavirus enteric infections on vaccine efficacy in a ROTASIIL clinical trial. Abraham D, Premkumar PS, Platts-Mills JA, et al. Am J Trop Med Hyg. 2024;110:1201–1209. doi: 10.4269/ajtmh.23-0348. [DOI] [PMC free article] [PubMed] [Google Scholar]
47.Epidemiology of norovirus disease in the first 2 years of life: a prospective multisite cohort study in Lima, Peru. Lanata CF, Soto G, Gil AI, et al. Int J Infect Dis. 2025;150:107308. doi: 10.1016/j.ijid.2024.107308. [DOI] [PubMed] [Google Scholar]
48.FilmArray™ GI panel performance for the diagnosis of acute gastroenteritis or hemorragic diarrhea. Piralla A, Lunghi G, Ardissino G, et al. BMC Microbiol. 2017;17:1–10. doi: 10.1186/s12866-017-1018-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
49.Potential diarrheal pathogens common also in healthy children in Angola. Pelkonen T, Dos Santos MD, Roine I, et al. Pediatr Infect Dis J. 2018;37:424–428. doi: 10.1097/INF.0000000000001781. [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Enteric pathogens relationship with small bowel histologic features of environmental enteric dysfunction in a multicountry cohort study. Iqbal NT, Lawrence S, Ahmed T, et al. Am J Clin Nutr. 2024;120:0. doi: 10.1016/j.ajcnut.2024.02.026. [DOI] [PubMed] [Google Scholar]
51.Etiology of diarrhea by multiplex polymerase chain reaction among young children in the United Arab Emirates: a case-control study. Alsuwaidi AR, Al Dhaheri K, Al Hamad S, et al. BMC Infect Dis. 2021;21:1–9. doi: 10.1186/s12879-020-05693-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
52.Common etiological agents in adult patients with gastroenteritis from Central Iran. Abbasi E, van Belkum A, Ghaznavi-Rad E. Microb Drug Resist. 2022;28:1043–1055. doi: 10.1089/mdr.2021.0177. [DOI] [PubMed] [Google Scholar]
53.Norovirus is the most frequent cause of diarrhea in hospitalized patients in Monterrey, Mexico. Casillas-Vega N, Flores-Rodríguez F, Sotelo-Coronado I, et al. Pathogens. 2020;9:672. doi: 10.3390/pathogens9090672. [DOI] [PMC free article] [PubMed] [Google Scholar]
54.Case-case analysis using 7 years of travelers' diarrhea surveillance data: preventive and travel medicine applications in Cusco, Peru. Jennings MC, Tilley DH, Ballard SB, et al. Am J Trop Med Hyg. 2017;96:1097–1106. doi: 10.4269/ajtmh.16-0633. [DOI] [PMC free article] [PubMed] [Google Scholar]
55.Application of a multiplex PCR assay for the detection of gastrointestinal pathogens in a rural African setting. Eibach D, Krumkamp R, Hahn A, et al. BMC Infect Dis. 2016;16:1–6. doi: 10.1186/s12879-016-1481-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
56.Investigation of the use of multiplex PCR in childhood diarrhea with clinical and epidemiological features. Kara Y, Kızıl MC, Kılıç Ö, Us T, Dinleyici EÇ. J Trop Pediatr. 2022;68:90. doi: 10.1093/tropej/fmac090. [DOI] [PubMed] [Google Scholar]
57.Comparative evaluation of two commercial multiplex panels for detection of gastrointestinal pathogens by use of clinical stool specimens. Khare R, Espy MJ, Cebelinski E, et al. J Clin Microbiol. 2014;52:3667–3673. doi: 10.1128/JCM.01637-14. [DOI] [PMC free article] [PubMed] [Google Scholar]
58.Enteropathogens in paediatric gastroenteritis: comparison of routine diagnostic and molecular methods. Tilmanne A, Martiny D, Quach C, Wautier M, Vandenberg O, Lepage P, Hallin M. Clin Microbiol Infect. 2019;25:1519–1524. doi: 10.1016/j.cmi.2019.07.021. [DOI] [PubMed] [Google Scholar]
59.Rapid molecular syndromic testing for aetiological diagnosis of gastrointestinal infections and targeted antimicrobial prescription: experience from a reference paediatric hospital in Spain. Castany-Feixas M, Simo S, Garcia-Garcia S, et al. Eur J Clin Microbiol Infect Dis. 2021;40:2153–2160. doi: 10.1007/s10096-021-04266-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
60.Risk factors for childhood enteric infection in urban Maputo, Mozambique: a cross-sectional study. Knee J, Sumner T, Adriano Z, et al. PLoS Negl Trop Dis. 2018;12:0. doi: 10.1371/journal.pntd.0006956. [DOI] [PMC free article] [PubMed] [Google Scholar]
61.Gastrointestinal panel performance for the diagnosis of acute gastroenteritis in pediatric patients. Sameer M, Masood A, Almutawea L, et al. Cureus. 2024;16:0. doi: 10.7759/cureus.61979. [DOI] [PMC free article] [PubMed] [Google Scholar]
62.Etiologies of mild and moderate diarrheal illness among children in Consuelo, Dominican Republic. Japa I, Ahmed D, Fernandez A, et al. Am J Trop Med Hyg. 2024;110:339–345. doi: 10.4269/ajtmh.23-0299. [DOI] [PMC free article] [PubMed] [Google Scholar]
63.Aetiology, epidemiology and clinical characteristics of acute moderate-to-severe diarrhoea in children under 5 years of age hospitalized in a referral paediatric hospital in Rabat, Morocco. Benmessaoud R, Jroundi I, Nezha M, et al. J Med Microbiol. 2015;64:84–92. doi: 10.1099/jmm.0.079830-0. [DOI] [PubMed] [Google Scholar]
64.Evaluation of a multiplex gastrointestinal PCR panel for the aetiological diagnosis of infectious diarrhoea. Leli C, Di Matteo L, Gotta F, et al. Infect Dis (Lond) 2020;52:114–120. doi: 10.1080/23744235.2019.1688861. [DOI] [PubMed] [Google Scholar]
65.Epidemiology of enterotoxigenic Escherichia coli infection in Minnesota, 2016-2017. Buuck S, Smith K, Fowler RC, Cebelinski E, Lappi V, Boxrud D, Medus C. Epidemiol Infect. 2020;148:0. doi: 10.1017/S0950268820001934. [DOI] [PMC free article] [PubMed] [Google Scholar]
66.Emerging trends in the epidemiology of human astrovirus infection among infants, children and adults hospitalized with acute watery diarrhea in Kolkata, India. Pativada M, Nataraju SM, Ganesh B, et al. Infect Genet Evol. 2012;12:1685–1693. doi: 10.1016/j.meegid.2012.07.018. [DOI] [PubMed] [Google Scholar]
67.Exploring the less common pathogens of infectious diarrhea. Toffel S, Velez L, Tremblay E, et al. J Microbiol Infect Dis. 2019;9:1–9. [Google Scholar]
68.Emerging trends in the etiology of enteric pathogens as evidenced from an active surveillance of hospitalized diarrhoeal patients in Kolkata, India. Nair GB, Ramamurthy T, Bhattacharya MK, et al. Gut Pathog. 2010;2:1–13. doi: 10.1186/1757-4749-2-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
69.Virulence-related genes and coenteropathogens associated with clinical outcomes of enteropathogenic Escherichia coli infections in children from the Brazilian semiarid region: a case-control study of diarrhea. Santos AK, de Medeiros PH, Bona MD, et al. J Clin Microbiol. 2019;57 doi: 10.1128/JCM.01777-18. [DOI] [PMC free article] [PubMed] [Google Scholar]
70.The spectrum of simultaneously detected pathogens identified in infections by the FilmArray panels. Tsagarakis NJ, Sideri A, Makridis P, Triantafyllou A, Stamoulakatou A, Papadogeorgaki E. https://www.researchgate.net/profile/Nikolaos-Tsagarakis-2/publication/320857001_The_spectrum_of_simultaneously_detected_pathogens_identified_in_infections_by_the_FilmArray_panels/links/5b6c91b0299bf14c6d97cd4b/The-spectrum-of-simultaneously-detected-pathogens-identified-in-infections-by-the-FilmArray-panels.pdf?origin=journalDetail&_tp=eyJwYWdlIjoiam91cm5hbERldGFpbCJ9https://www.researchgate.net/profile/Nikolaos-Tsagarakis-2/publication/320857001_The_spectrum_of_simultaneously_detected_pathogens_identified_in_infections_by_the_FilmArray_panels/links/5b6c91b0299bf14c6d97cd4b/The-spectrum-of-simultaneously-detected-pathogens-identified-in-infections-by-the-FilmArray-panels.pdf?origin=journalDetail&_tp=eyJwYWdlIjoiam91cm5hbERldGFpbCJ9 Acta Microbiol Hell. 2017;62:152–159. [Google Scholar]
71.Mapping of etiologies of computed tomography-proven acute colitis: a prospective cohort study. Meyer J, Schrenzel J, Balaphas A, et al. Sci Rep. 2022;12:9730. doi: 10.1038/s41598-022-13868-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
72.The impact of a positive Biofire® FilmArray® gastrointestinal panel result on clinical management and outcomes. Carmon D, Rohana H, Azrad M, Peretz A. Diagnostics (Basel) 2023;13:1094. doi: 10.3390/diagnostics13061094. [DOI] [PMC free article] [PubMed] [Google Scholar]
73.Aetiology of acute paediatric gastroenteritis in Bulgaria during summer months: prevalence of viral infections. Mladenova Z, Steyer A, Steyer AF, Ganesh B, Petrov P, Tchervenjakova T, Iturriza-Gomara M. J Med Microbiol. 2015;64:272–282. doi: 10.1099/jmm.0.000018. [DOI] [PubMed] [Google Scholar]
74.Improved diagnosis of gastrointestinal infections using a semi-automated multiplex real-time PCR for detection of enteropathogens. Fidalgo B, Rubio E, Pastor V, et al. J Med Microbiol. 2021;70:1367. doi: 10.1099/jmm.0.001367. [DOI] [PubMed] [Google Scholar]
75.Systematic application of multiplex PCR enhances the detection of bacteria, parasites, and viruses in stool samples. McAuliffe GN, Anderson TP, Stevens M, et al. J Infect. 2013;67:122–129. doi: 10.1016/j.jinf.2013.04.009. [DOI] [PubMed] [Google Scholar]
76.Estimating deaths from foodborne disease in the UK for 11 key pathogens. Holland D, Thomson L, Mahmoudzadeh N, Khaled A. https://bmjopengastro.bmj.com/content/7/1/e000377. BMJ Open Gastroenterol. 2020;7:377. doi: 10.1136/bmjgast-2020-000377. [DOI] [PMC free article] [PubMed] [Google Scholar]
77.A multi-pathogen retrospective study in patients hospitalized for acute gastroenteritis. Zizza A, Guido M, Sedile R, et al. Diseases. 2024;12:213. doi: 10.3390/diseases12090213. [DOI] [PMC free article] [PubMed] [Google Scholar]
78.Etiology of diarrhea in young children in Denmark: a case-control study. Olesen B, Neimann J, Böttiger B, et al. J Clin Microbiol. 2005;43:3636–3641. doi: 10.1128/JCM.43.8.3636-3641.2005. [DOI] [PMC free article] [PubMed] [Google Scholar]
79.Multiplex PCR reveals a high prevalence of multiple pathogens in traveller's diarrhoea in children. Pouletty M, De Pontual L, Lopez M, et al. Arch Dis Child. 2019;104:141–146. doi: 10.1136/archdischild-2017-314327. [DOI] [PubMed] [Google Scholar]
80.Potentially pathogenic organisms in stools and their association with acute diarrheal illness in children aged <2 years. Mihala G, Ware RS, Lambert SB, et al. J Pediatric Infect Dis Soc. 2022;11:199–206. doi: 10.1093/jpids/piab130. [DOI] [PubMed] [Google Scholar]
81.Etiology of acute diarrhea in Tunisian children with emphasis on diarrheagenic Escherichia coli: prevalence and identification of E. coli virulence markers. Ben Salem-Ben NI, Hassine ZM, Hassine F, Sdir-Loulizi K, Ben SM, Aouni M, Mzoughi R. https://pmc.ncbi.nlm.nih.gov/articles/PMC4401059/#abstract1. Iran J Public Health. 2014;43:947–960. [PMC free article] [PubMed] [Google Scholar]
82.Giardia and Cryptosporidium in children with diarrhea, Kufra, Libya, a North African migration route city. Saaed FM, Ongerth JE. Int J Hyg Environ Health. 2019;222:840–846. doi: 10.1016/j.ijheh.2019.04.006. [DOI] [PubMed] [Google Scholar]
83.Etiology and epidemiology of diarrhea in hospitalized children from low income country: a matched case-control study in Central African Republic. Breurec S, Vanel N, Bata P, et al. PLoS Negl Trop Dis. 2016;10:0. doi: 10.1371/journal.pntd.0004283. [DOI] [PMC free article] [PubMed] [Google Scholar]
84.Evaluation of the BioFire FilmArray® GastrointestinalPanel in a Midwestern Academic Hospital. Murphy CN, Fowler RC, Iwen PC, Fey PD. Eur J Clin Microbiol Infect Dis. 2017;36:747–754. doi: 10.1007/s10096-016-2858-7. [DOI] [PubMed] [Google Scholar]
85.Evaluation of the xTAG gastrointestinal pathogen panel assay for the detection of enteric pathogens in Kuwait. Albert MJ, Rotimi VO, Iqbal J, Chehadeh W. Med Princ Pract. 2016;25:472–476. doi: 10.1159/000447698. [DOI] [PMC free article] [PubMed] [Google Scholar]
86.Modeling solutions for microbial water contamination in the global south for public health protection. Izah SC, Ogwu MC. Front Microbiol. 2025;16:1504829. doi: 10.3389/fmicb.2025.1504829. [DOI] [PMC free article] [PubMed] [Google Scholar]
87.Prevalence and diversity of intestinal parasites in children around the world. D'Alessandro AB, Pedreira LE, Farias GS. Rev Gest Soc Ambient. 2024;18:1–12. [Google Scholar]
88.The global prevalence of Cyclospora cayetanensis infection: a systematic review, meta-analysis, and meta-regression. Chen Y, Qin Z, Li J, Xiao L, Zhang L. Acta Trop. 2024;253:107175. doi: 10.1016/j.actatropica.2024.107175. [DOI] [PubMed] [Google Scholar]
89.Spatial and temporal trends in HIV/AIDS burden among South Asian countries from 1990 to 2021: a systematic examination of the Global Burden of Disease study 2021. Akashanand Akashanand, Khatib MN, Serhan HA, et al. HIV Med. 2025;26:734–747. doi: 10.1111/hiv.70003. [DOI] [PMC free article] [PubMed] [Google Scholar]
90.Sources and prevalence of Cyclospora cayetanensis in southeastern US growing environments. Kahler AM, Hofstetter J, Arrowood M, et al. J Food Prot. 2024;87:100309. doi: 10.1016/j.jfp.2024.100309. [DOI] [PMC free article] [PubMed] [Google Scholar]
91.Global prevalence of Giardia infection in nonhuman mammalian hosts: a systematic review and meta-analysis of five million animals. Hatam-Nahavandi K, Ahmadpour E, Badri M, Eslahi AV, Anvari D, Carmena D, Xiao L. PLoS Negl Trop Dis. 2025;19:0. doi: 10.1371/journal.pntd.0013021. [DOI] [PMC free article] [PubMed] [Google Scholar]
92.The epidemiology and burden of injury in countries of the Association of Southeast Asian Nations (ASEAN), 1990-2021: findings from the Global Burden of Disease Study. van der Lubbe SC, Chong LS, Hay SI, et al. https://www.thelancet.com/action/showPdf?pii=S2468-2667%2825%2900069-6. Lancet Public Health. 2025;10:456–466. doi: 10.1016/S2468-2667(25)00069-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
93.Prevalence of intestinal parasites, with emphasis on the molecular epidemiology of Giardia duodenalis and Blastocystis sp., in the Paranaguá Bay, Brazil: a community survey. Seguí R, Muñoz-Antoli C, Klisiowicz DR, et al. Parasit Vectors. 2018;11:1–19. doi: 10.1186/s13071-018-3054-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
94.Multilocus genotyping of Giardia duodenalis in mostly asymptomatic indigenous people from the Tapirapé Tribe, Brazilian Amazon. Köster PC, Malheiros AF, Shaw JJ, et al. Pathogens. 2021;10:206. doi: 10.3390/pathogens10020206. [DOI] [PMC free article] [PubMed] [Google Scholar]
95.Parasitic infections among patients hospitalized in the Tropical and Parasitic Clinic of Poznan University of Medical Sciences, Poland between 2015 and 2018. Is there a relationship between protozoa infection and gastrointestinal symptoms? Pielok ŁA, Kłudkowska M, Frąckowiak K, Stefaniak J. Prz Gastroenterol. 2022;17:310–315. doi: 10.5114/pg.2022.121823. [DOI] [PMC free article] [PubMed] [Google Scholar]
96.Cryptosporidium and Giardia in Africa: current and future challenges. Squire SA, Ryan U. Parasit Vectors. 2017;10:1–32. doi: 10.1186/s13071-017-2111-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
97.Krumrie S. Glasgow: University of Glasgow; 2022. Molecular epidemiology of Giardia duodenalis in the high-income world University of Glasgow [Master's Thesis] [Google Scholar]
98.Molecular epidemiology of Cryptosporidium parvum and Giardia lamblia in different water bodies, soil, and vegetables in Pakistan. Abbas Z, Khan MK, Abbas RZ, et al. Health Secur. 2022;20:308–320. doi: 10.1089/hs.2021.0118. [DOI] [PubMed] [Google Scholar]
99.Waterborne transmission of protozoan parasites: a review of worldwide outbreaks - an update 2017-2022. Bourli P, Eslahi AV, Tzoraki O, Karanis P. J Water Health. 2023;21:1421–1447. doi: 10.2166/wh.2023.094. [DOI] [PubMed] [Google Scholar]
100.Cryptosporidium infections in Nepal: a narrative review. Dhakal P, Li J, Zhang L. One Health Bull. 2023;3:13. [Google Scholar]
101.Molecular methods for diagnosis of Entamoeba histolytica in a clinical setting: an overview. Paul J, Srivastava S, Bhattacharya S. Exp Parasitol. 2007;116:35–43. doi: 10.1016/j.exppara.2006.11.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
102.A scoping review of the detection, epidemiology and control of Cyclospora cayetanensis with an emphasis on produce, water and soil. Totton SC, O'Connor AM, Naganathan T, Martinez BA, Vriezen ER, Torrence ME, Sargeant JM. Epidemiol Infect. 2021;149:0. doi: 10.1017/S0950268821000200. [DOI] [PMC free article] [PubMed] [Google Scholar]
103.In pediatric gastroenteritis: the presence of Helicobacter pylori prevalence of Entamoeba histolytica, Giardia intestinalis and Cryptosporidium spp. Çelebi D, Çelebi Ö. https://dergipark.org.tr/en/download/article-file/1945124 Dicle Tıp Dergisi. 2021;48:425–430. [Google Scholar]
104.Epidemiology of Blastocystis infection: a review of data from Poland in relation to other reports. Rudzińska M, Sikorska K. Pathogens. 2023;12:1050. doi: 10.3390/pathogens12081050. [DOI] [PMC free article] [PubMed] [Google Scholar]
105.Blastocystis spp. and other intestinal parasites in Polish soldiers deployed to Lebanon and Iraq. Kosik-Bogacka DI, Korzeniewski K, Łanocha-Arendarczyk N, Korycińska J, Lepczyńska M, Dzika E, Marchelek-Myśliwiec M. Pathogens. 2024;13:271. doi: 10.3390/pathogens13030271. [DOI] [PMC free article] [PubMed] [Google Scholar]
106.Christopher JP. Georgia: University of Georgia; 2021. Parasite: Host, and Environmental Traits Predict the Zoonotic Risk of Protozoan Parasites [Thesis] [Google Scholar]
107.Molecular-based diagnosis of Entamoeba histolytica infection. Huston CD, Haque R, Petri WA Jr. Expert Rev Mol Med. 1999;1:1–11. doi: 10.1017/S1462399499000599. [DOI] [PubMed] [Google Scholar]
108.Clinical molecular and genomic epidemiology of Morganella morganii in China. Xiang G, Lan K, Cai Y, et al. Front Microbiol. 2021;12:744291. doi: 10.3389/fmicb.2021.744291. [DOI] [PMC free article] [PubMed] [Google Scholar]
109.Development of a molecular serotyping scheme for Morganella morganii. Liu B, Guo X, Wang J, et al. Front Microbiol. 2021;12:791165. doi: 10.3389/fmicb.2021.791165. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF1] 1.Meki DC. South Africa: University of Pretoria; 2023. Framework for mitigating the risk of waterborne diarrheal diseases in peri-urban areas of Lusaka district Zambia [PhD Thesis] [Google Scholar]

[REF2] 2.Review on emerging waterborne pathogens in Africa: the case of Cryptosporidium. Kombo Mpindou GM, Bueno IE, Ramón EC. Water. 2021;13:2966. [Google Scholar]

[REF3] 3.Challenge of diagnosing acute infections in poor resource settings in Africa. Chidzwondo F, Mutapi F. AAS Open Res. 2024;4:28. [Google Scholar]

[REF4] 4.Global, regional, and national age-sex-specific burden of diarrhoeal diseases, their risk factors, and aetiologies, 1990-2021, for 204 countries and territories: a systematic analysis for the Global Burden of Disease Study 2021. GBD 2021 Diarrhoeal Diseases Collaborators. Lancet Infect Dis. 2025;25:519–536. doi: 10.1016/S1473-3099(24)00691-1. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF5] 5.Global, regional, and national age-sex-specific burden of diarrhoeal diseases, their risk factors, and aetiologies, 1990-2021, for 204 countries and territories: a systematic analysis for the Global Burden of Disease Study. Kyu HH, Vongpradith A, Dominguez R-MV, et al. https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(24)00691-1.pdf. Lancet Infect Dis. 2025;25:519–556. doi: 10.1016/S1473-3099(24)00691-1. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF6] 6.Global burden of diarrhea disease in the older adult and its attributable risk factors from 1990 to 2021: a comprehensive analysis from the global burden of disease study 2021. Zhao WZ, Wang JY, Zhang MN, Wu SN, Dai WJ, Yang XZ, Wang HG. Front Public Health. 2025;13:1541492. doi: 10.3389/fpubh.2025.1541492. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF7] 7.Acute lower respiratory infections among children under five in Sub-Saharan Africa: a scoping review of prevalence and risk factors. Sarfo JO, Amoadu M, Gyan TB, et al. BMC Pediatr. 2023;23:225. doi: 10.1186/s12887-023-04033-x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF8] 8.Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): an umbrella review. Besnier E, Thomson K, Stonkute D, et al. PLoS One. 2021;16:0. doi: 10.1371/journal.pone.0251905. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF9] 9.Baral B, Mamale K, Gairola S, Chauhan C, Dey A, Kaundal RK. Nanostructured Drug Delivery Systems in Infectious Disease Treatment. Amsterdam, Netherland: Elsevier; 2024. Infectious diseases and its global epidemiology; pp. 1–24. [Google Scholar]

[REF10] 10.Use-case scenarios for an anti-Cryptosporidium therapeutic. Ashigbie PG, Shepherd S, Steiner KL, et al. PLoS Negl Trop Dis. 2021;15:0. doi: 10.1371/journal.pntd.0009057. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF11] 11.Prevalence of Cryptosporidium and Giardia infections in under-five children with diarrhoea in Blantyre, Malawi. Bitilinyu-Bangoh JE, Riesebosch S, Rebel M, Chiwaya P, Verschoor SP, Voskuijl WP, Schallig HD. BMC Infect Dis. 2024;24:68. doi: 10.1186/s12879-024-08979-w. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF12] 12.Clinical significance of respiratory involvement in Cryptosporidiosis: cross-sectional study of children with diarrhea and respiratory symptoms in Uganda. Mor SM, Ndeezi G, Ascolillo LR, et al. Am J Trop Med Hyg. 2024;111:796–803. doi: 10.4269/ajtmh.24-0112. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF13] 13.Cryptosporidiosis in a zoonotic gastrointestinal disorder perspective: present status, risk factors, pathophysiology, and treatment, particularly in immunocompromised patients. Balendran T, Iddawela D, Lenadora S. J Trop Med. 2024;2024:6439375. doi: 10.1155/2024/6439375. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF14] 14.Giardia duodenalis in human health: a comprehensive review of its epidemiology, transmission, pathophysiology, diagnostics, and control strategies. Barasa E, Indusa W, Were T. AEJI. 2025;15:109–126. [Google Scholar]

[REF15] 15.Geboes K, Jouret‐Mourin A. Morson and Dawson's Gastrointestinal Pathology. New Jersey, US: Wiley; 2024. Inflammatory disorders of the small intestine ; pp. 397–461. [Google Scholar]

[REF16] 16.Food and drinking water as sources of pathogenic protozoans: an update. Rossi F, Santonicola S, Amadoro C, Marino L, Colavita G. Appl Sci. 2024;14:5339. [Google Scholar]

[REF17] 17.Upadhyay SK, Singh M, Sharma AK. New Developments in Medical Research. New York, US: Nova Science Publishers Inc; 2024. Therapeutic advances in human health and diseases. [Google Scholar]

[REF18] 18.The association between climatic factors and waterborne infectious outbreaks with a focus on vulnerability in Pakistan: integrative review. Sharif F, Shahzad L, Batool M. Int J Environ Health Res. 2024;34:3299–3316. doi: 10.1080/09603123.2024.2302040. [DOI] [PubMed] [Google Scholar]

[REF19] 19.Utami WS. Intestinal Parasites - New Developments in Diagnosis, Treatment, Prevention and Future Directions. London, UK: IntechOpen; 2024. Zoonotic risk of Cryptosporidium spp. prevention with One Health approach in Indonesia. [Google Scholar]

[REF20] 20.Reyes R, Ahn R, Thurber K, Burke TF. Insight into Epidemiology. New York, US: Springer; 2024. Urbanization and Infectious Disease Dynamics: Examining the Health Risks of Rapid Urban Growth; pp. 123–146. [Google Scholar]

[REF21] 21.Jasuja JK. Saarbrücken, Germany: Saarländische Universitäts- und Landesbibliothek; 2024. Application of stool-based multiplex real-time PCR for persistent digestive disorders in Mali and Côte d'Ivoire [Dissertation] [Google Scholar]

[REF22] 22.Akinnubi T. Intestinal Parasites - New Developments in Diagnosis, Treatment, Prevention and Future Directions. London, UK: IntechOpen; 2024. Cryptosporidium spp.: challenges in control and potential therapeutic strategies; pp. 91–107. [Google Scholar]

[REF23] 23.Muyyarikkandy MS, Kniel K, Bower WA, Vieira AR, Negrón ME, Thakur S. Modernizing Global Health Security to Prevent, Detect, and Respond. Amsterdam, Netherlands: Elsevier; 2024. Assessment of critical gaps in prevention, control, and response to major bacterial, viral, and protozoal infectious diseases at the human, animal, and environmental interface; pp. 175–195. [Google Scholar]

[REF24] 24.Tackling infectious diseases in the Caribbean and South America: epidemiological insights, antibiotic resistance, associated infectious diseases in immunological disorders, global infection response, and experimental anti-idiotypic vaccine candidates against microorganisms of public health importance. Justiz-Vaillant A, Soodeen S, Gopaul D, et al. Microorganisms. 2025;13:282. doi: 10.3390/microorganisms13020282. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF25] 25.Imam FB, Darmstadt GL, Zaidi AK. Remington and Klein's Infectious Diseases of the Fetus and Newborn E-Book. Amsterdam, Netherlands: Elsevier; 2025. Neonatal infections: a global perspective; pp. 24–53. [Google Scholar]

[REF26] 26.Etiology of acute diarrheal disease and antimicrobial susceptibility pattern in children younger than 5 years old in Nepal. Shrestha SK, Shrestha J, Mason CJ, et al. Am J Trop Med Hyg. 2023;108:174–180. doi: 10.4269/ajtmh.21-1219. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF27] 27.Etiology of acute gastroenteritis among children less than 5 years of age in Bucaramanga, Colombia: a case-control study. Farfán-García AE, Imdad A, Zhang C, et al. PLoS Negl Trop Dis. 2020;14:0. doi: 10.1371/journal.pntd.0008375. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF28] 28.Case-control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. Albert MJ, Faruque AS, Faruque SM, Sack RB, Mahalanabis D. J Clin Microbiol. 1999;37:3458–3464. doi: 10.1128/jcm.37.11.3458-3464.1999. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF29] 29.Etiological agents of diarrhea in hospitalized pediatric patients with special emphasis on diarrheagenic Escherichia coli in North India. Verma S, Venkatesh V, Kumar R, et al. J Lab Physicians. 2019;11:68–74. doi: 10.4103/JLP.JLP_123_18. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF30] 30.Etiology of acute gastroenteritis in three sentinel general practices, Austria 2007. Huhulescu S, Kiss R, Brettlecker M, Cerny RJ, Hess C, Wewalka G, Allerberger F. Infection. 2009;37:103–108. doi: 10.1007/s15010-008-8106-z. [DOI] [PubMed] [Google Scholar]

[REF31] 31.A molecular study on the prevalence and coinfections of Rotavirus, Norovirus, Astrovirus and Adenovirus in children with gastroenteritis. Aktaş O, Aydin H, Timurkan MO. Minerva Pediatr. 2019;71:431–437. doi: 10.23736/S0026-4946.16.04304-X. [DOI] [PubMed] [Google Scholar]

[REF32] 32.Changes in causes of acute gastroenteritis in the United Kingdom over 15 years: microbiologic findings from 2 prospective, population-based studies of infectious intestinal disease. Tam CC, O'Brien SJ, Tompkins DS, et al. Clin Infect Dis. 2012;54:1275–1286. doi: 10.1093/cid/cis028. [DOI] [PubMed] [Google Scholar]

[REF33] 33.High frequency of enteric protozoan, viral, and bacterial potential pathogens in community-acquired acute diarrheal episodes: evidence based on results of luminex gastrointestinal pathogen panel assay. Hawash YA, Ismail KA, Almehmadi M. Korean J Parasitol. 2017;55:513–521. doi: 10.3347/kjp.2017.55.5.513. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF34] 34.Bacterial, viral and parasitic enteric pathogens associated with acute diarrhea in hospitalized children from northern Jordan. Youssef M, Shurman A, Bougnoux M, Rawashdeh M, Bretagne S, Strockbine N. FEMS Immunol Med Microbiol. 2000;28:257–263. doi: 10.1111/j.1574-695X.2000.tb01485.x. [DOI] [PubMed] [Google Scholar]

[REF35] 35.Prevalence and diversity of enteric pathogens among cholera treatment centre patients with acute diarrhea in Uvira, Democratic Republic of Congo. Williams C, Cumming O, Grignard L, et al. BMC Infect Dis. 2020;20:741. doi: 10.1186/s12879-020-05454-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF36] 36.Descriptive epidemiology of enteric disease in Chennai, India. Chopra RD, Dworkin MS. Epidemiol Infect. 2013;141:953–957. doi: 10.1017/S0950268812001409. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF37] 37.Ng’ang’a GW. JKUAT-COHES. Kenya: Jomo Kenyatta University of Agriculture and Technology; 2018. Bacterial and Parasitic Co-Infections, Antimicrobial Susceptibility and ESBL Genes Carriage in Bacteria Isolated from Children below 5 Years with Diarrhea Attending Mukuru Slum Health Clinics [Master's thesis] [Google Scholar]

[REF38] 38.Giardia duodenalis assemblages associated with diarrhea in children in South India identified by PCR-RFLP. Ajjampur SS, Sankaran P, Kannan A, Sathyakumar K, Sarkar R, Gladstone BP, Kang G. https://pmc.ncbi.nlm.nih.gov/articles/PMC3909731/pdf/nihms545838.pdf. Am J Trop Med Hyg. 2009;80:16–19. [PMC free article] [PubMed] [Google Scholar]

[REF39] 39.Etiology of acute diarrhea in children and adults in Tunis, Tunisia, with emphasis on diarrheagenic Escherichia coli: prevalence, phenotyping, and molecular epidemiology. Al-Gallas N, Bahri O, Bouratbeen A, Haasen AB, Aissa RB. https://riip.hal.science/pasteur-01375250/file/Etiology%20of%20Acute%20Diarrhea.pdf. Am J Trop Med Hyg. 2007;77:571–582. [PubMed] [Google Scholar]

[REF40] 40.Etiology of children's diarrhea in Montevideo, Uruguay: associated pathogens and unusual isolates. Torres ME, Pírez MC, Schelotto F, et al. J Clin Microbiol. 2001;39:2134–2139. doi: 10.1128/JCM.39.6.2134-2139.2001. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF41] 41.High burden of co-infection with multiple enteric pathogens in children suffering with diarrhoea from rural and peri-urban communities in South Africa. Potgieter N, Heine L, Ngandu JP, et al. Pathogens. 2023;12:315. doi: 10.3390/pathogens12020315. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF42] 42.Makhari Z. Makhari Z: Characterization of bacterial causes of diarrhoea in an under-five population in South Africa. Johannesburg, South Africa. 2012. https://www.google.com/url?sa=i&url=https%3A%2F%2Ftwas.org%2Fsites%2Fdefault%2Ffiles%2Fcv%2Fcv._prof_shabir_madhi.2022_sam.doc&psig=AOvVaw2zVDTfRn6lqG0gtr4OIm87&ust=1757009697372000&source=images&cd=vfe&opi=89978449&ved=0CAcQr5oMahcKEwjY2rSomb2PAxUAAAAAHQAAAAAQBA https://www.google.com/url?sa=i&url=https%3A%2F%2Ftwas.org%2Fsites%2Fdefault%2Ffiles%2Fcv%2Fcv._prof_shabir_madhi.2022_sam.doc&psig=AOvVaw2zVDTfRn6lqG0gtr4OIm87&ust=1757009697372000&source=images&cd=vfe&opi=89978449&ved=0CAcQr5oMahcKEwjY2rSomb2PAxUAAAAAHQAAAAAQBA

[REF43] 43.Multiple etiologies of infectious diarrhea and concurrent infections in a pediatric outpatient-based screening study in Odisha, India. Shrivastava AK, Kumar S, Mohakud NK, Suar M, Sahu PS. Gut Pathog. 2017;9:1–12. doi: 10.1186/s13099-017-0166-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF44] 44.Detection of common diarrhea-causing pathogens in Northern Taiwan by multiplex polymerase chain reaction. Huang SH, Lin YF, Tsai MH, Yang S, Liao ML, Chao SW, Hwang CC. Medicine (Baltimore) 2018;97:0. doi: 10.1097/MD.0000000000011006. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF45] 45.Aetiology of traveller's diarrhoea: evaluation of a multiplex PCR tool to detect different enteropathogens. Zboromyrska Y, Hurtado JC, Salvador P, et al. Clin Microbiol Infect. 2014;20:0. doi: 10.1111/1469-0691.12621. [DOI] [PubMed] [Google Scholar]

[REF46] 46.Effect of non-rotavirus enteric infections on vaccine efficacy in a ROTASIIL clinical trial. Abraham D, Premkumar PS, Platts-Mills JA, et al. Am J Trop Med Hyg. 2024;110:1201–1209. doi: 10.4269/ajtmh.23-0348. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF47] 47.Epidemiology of norovirus disease in the first 2 years of life: a prospective multisite cohort study in Lima, Peru. Lanata CF, Soto G, Gil AI, et al. Int J Infect Dis. 2025;150:107308. doi: 10.1016/j.ijid.2024.107308. [DOI] [PubMed] [Google Scholar]

[REF48] 48.FilmArray™ GI panel performance for the diagnosis of acute gastroenteritis or hemorragic diarrhea. Piralla A, Lunghi G, Ardissino G, et al. BMC Microbiol. 2017;17:1–10. doi: 10.1186/s12866-017-1018-2. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF49] 49.Potential diarrheal pathogens common also in healthy children in Angola. Pelkonen T, Dos Santos MD, Roine I, et al. Pediatr Infect Dis J. 2018;37:424–428. doi: 10.1097/INF.0000000000001781. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF50] 50.Enteric pathogens relationship with small bowel histologic features of environmental enteric dysfunction in a multicountry cohort study. Iqbal NT, Lawrence S, Ahmed T, et al. Am J Clin Nutr. 2024;120:0. doi: 10.1016/j.ajcnut.2024.02.026. [DOI] [PubMed] [Google Scholar]

[REF51] 51.Etiology of diarrhea by multiplex polymerase chain reaction among young children in the United Arab Emirates: a case-control study. Alsuwaidi AR, Al Dhaheri K, Al Hamad S, et al. BMC Infect Dis. 2021;21:1–9. doi: 10.1186/s12879-020-05693-1. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF52] 52.Common etiological agents in adult patients with gastroenteritis from Central Iran. Abbasi E, van Belkum A, Ghaznavi-Rad E. Microb Drug Resist. 2022;28:1043–1055. doi: 10.1089/mdr.2021.0177. [DOI] [PubMed] [Google Scholar]

[REF53] 53.Norovirus is the most frequent cause of diarrhea in hospitalized patients in Monterrey, Mexico. Casillas-Vega N, Flores-Rodríguez F, Sotelo-Coronado I, et al. Pathogens. 2020;9:672. doi: 10.3390/pathogens9090672. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF54] 54.Case-case analysis using 7 years of travelers' diarrhea surveillance data: preventive and travel medicine applications in Cusco, Peru. Jennings MC, Tilley DH, Ballard SB, et al. Am J Trop Med Hyg. 2017;96:1097–1106. doi: 10.4269/ajtmh.16-0633. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF55] 55.Application of a multiplex PCR assay for the detection of gastrointestinal pathogens in a rural African setting. Eibach D, Krumkamp R, Hahn A, et al. BMC Infect Dis. 2016;16:1–6. doi: 10.1186/s12879-016-1481-7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF56] 56.Investigation of the use of multiplex PCR in childhood diarrhea with clinical and epidemiological features. Kara Y, Kızıl MC, Kılıç Ö, Us T, Dinleyici EÇ. J Trop Pediatr. 2022;68:90. doi: 10.1093/tropej/fmac090. [DOI] [PubMed] [Google Scholar]

[REF57] 57.Comparative evaluation of two commercial multiplex panels for detection of gastrointestinal pathogens by use of clinical stool specimens. Khare R, Espy MJ, Cebelinski E, et al. J Clin Microbiol. 2014;52:3667–3673. doi: 10.1128/JCM.01637-14. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF58] 58.Enteropathogens in paediatric gastroenteritis: comparison of routine diagnostic and molecular methods. Tilmanne A, Martiny D, Quach C, Wautier M, Vandenberg O, Lepage P, Hallin M. Clin Microbiol Infect. 2019;25:1519–1524. doi: 10.1016/j.cmi.2019.07.021. [DOI] [PubMed] [Google Scholar]

[REF59] 59.Rapid molecular syndromic testing for aetiological diagnosis of gastrointestinal infections and targeted antimicrobial prescription: experience from a reference paediatric hospital in Spain. Castany-Feixas M, Simo S, Garcia-Garcia S, et al. Eur J Clin Microbiol Infect Dis. 2021;40:2153–2160. doi: 10.1007/s10096-021-04266-7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF60] 60.Risk factors for childhood enteric infection in urban Maputo, Mozambique: a cross-sectional study. Knee J, Sumner T, Adriano Z, et al. PLoS Negl Trop Dis. 2018;12:0. doi: 10.1371/journal.pntd.0006956. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF61] 61.Gastrointestinal panel performance for the diagnosis of acute gastroenteritis in pediatric patients. Sameer M, Masood A, Almutawea L, et al. Cureus. 2024;16:0. doi: 10.7759/cureus.61979. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF62] 62.Etiologies of mild and moderate diarrheal illness among children in Consuelo, Dominican Republic. Japa I, Ahmed D, Fernandez A, et al. Am J Trop Med Hyg. 2024;110:339–345. doi: 10.4269/ajtmh.23-0299. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF63] 63.Aetiology, epidemiology and clinical characteristics of acute moderate-to-severe diarrhoea in children under 5 years of age hospitalized in a referral paediatric hospital in Rabat, Morocco. Benmessaoud R, Jroundi I, Nezha M, et al. J Med Microbiol. 2015;64:84–92. doi: 10.1099/jmm.0.079830-0. [DOI] [PubMed] [Google Scholar]

[REF64] 64.Evaluation of a multiplex gastrointestinal PCR panel for the aetiological diagnosis of infectious diarrhoea. Leli C, Di Matteo L, Gotta F, et al. Infect Dis (Lond) 2020;52:114–120. doi: 10.1080/23744235.2019.1688861. [DOI] [PubMed] [Google Scholar]

[REF65] 65.Epidemiology of enterotoxigenic Escherichia coli infection in Minnesota, 2016-2017. Buuck S, Smith K, Fowler RC, Cebelinski E, Lappi V, Boxrud D, Medus C. Epidemiol Infect. 2020;148:0. doi: 10.1017/S0950268820001934. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF66] 66.Emerging trends in the epidemiology of human astrovirus infection among infants, children and adults hospitalized with acute watery diarrhea in Kolkata, India. Pativada M, Nataraju SM, Ganesh B, et al. Infect Genet Evol. 2012;12:1685–1693. doi: 10.1016/j.meegid.2012.07.018. [DOI] [PubMed] [Google Scholar]

[REF67] 67.Exploring the less common pathogens of infectious diarrhea. Toffel S, Velez L, Tremblay E, et al. J Microbiol Infect Dis. 2019;9:1–9. [Google Scholar]

[REF68] 68.Emerging trends in the etiology of enteric pathogens as evidenced from an active surveillance of hospitalized diarrhoeal patients in Kolkata, India. Nair GB, Ramamurthy T, Bhattacharya MK, et al. Gut Pathog. 2010;2:1–13. doi: 10.1186/1757-4749-2-4. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF69] 69.Virulence-related genes and coenteropathogens associated with clinical outcomes of enteropathogenic Escherichia coli infections in children from the Brazilian semiarid region: a case-control study of diarrhea. Santos AK, de Medeiros PH, Bona MD, et al. J Clin Microbiol. 2019;57 doi: 10.1128/JCM.01777-18. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF70] 70.The spectrum of simultaneously detected pathogens identified in infections by the FilmArray panels. Tsagarakis NJ, Sideri A, Makridis P, Triantafyllou A, Stamoulakatou A, Papadogeorgaki E. https://www.researchgate.net/profile/Nikolaos-Tsagarakis-2/publication/320857001_The_spectrum_of_simultaneously_detected_pathogens_identified_in_infections_by_the_FilmArray_panels/links/5b6c91b0299bf14c6d97cd4b/The-spectrum-of-simultaneously-detected-pathogens-identified-in-infections-by-the-FilmArray-panels.pdf?origin=journalDetail&_tp=eyJwYWdlIjoiam91cm5hbERldGFpbCJ9https://www.researchgate.net/profile/Nikolaos-Tsagarakis-2/publication/320857001_The_spectrum_of_simultaneously_detected_pathogens_identified_in_infections_by_the_FilmArray_panels/links/5b6c91b0299bf14c6d97cd4b/The-spectrum-of-simultaneously-detected-pathogens-identified-in-infections-by-the-FilmArray-panels.pdf?origin=journalDetail&_tp=eyJwYWdlIjoiam91cm5hbERldGFpbCJ9 Acta Microbiol Hell. 2017;62:152–159. [Google Scholar]

[REF71] 71.Mapping of etiologies of computed tomography-proven acute colitis: a prospective cohort study. Meyer J, Schrenzel J, Balaphas A, et al. Sci Rep. 2022;12:9730. doi: 10.1038/s41598-022-13868-w. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF72] 72.The impact of a positive Biofire® FilmArray® gastrointestinal panel result on clinical management and outcomes. Carmon D, Rohana H, Azrad M, Peretz A. Diagnostics (Basel) 2023;13:1094. doi: 10.3390/diagnostics13061094. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF73] 73.Aetiology of acute paediatric gastroenteritis in Bulgaria during summer months: prevalence of viral infections. Mladenova Z, Steyer A, Steyer AF, Ganesh B, Petrov P, Tchervenjakova T, Iturriza-Gomara M. J Med Microbiol. 2015;64:272–282. doi: 10.1099/jmm.0.000018. [DOI] [PubMed] [Google Scholar]

[REF74] 74.Improved diagnosis of gastrointestinal infections using a semi-automated multiplex real-time PCR for detection of enteropathogens. Fidalgo B, Rubio E, Pastor V, et al. J Med Microbiol. 2021;70:1367. doi: 10.1099/jmm.0.001367. [DOI] [PubMed] [Google Scholar]

[REF75] 75.Systematic application of multiplex PCR enhances the detection of bacteria, parasites, and viruses in stool samples. McAuliffe GN, Anderson TP, Stevens M, et al. J Infect. 2013;67:122–129. doi: 10.1016/j.jinf.2013.04.009. [DOI] [PubMed] [Google Scholar]

[REF76] 76.Estimating deaths from foodborne disease in the UK for 11 key pathogens. Holland D, Thomson L, Mahmoudzadeh N, Khaled A. https://bmjopengastro.bmj.com/content/7/1/e000377. BMJ Open Gastroenterol. 2020;7:377. doi: 10.1136/bmjgast-2020-000377. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF77] 77.A multi-pathogen retrospective study in patients hospitalized for acute gastroenteritis. Zizza A, Guido M, Sedile R, et al. Diseases. 2024;12:213. doi: 10.3390/diseases12090213. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF78] 78.Etiology of diarrhea in young children in Denmark: a case-control study. Olesen B, Neimann J, Böttiger B, et al. J Clin Microbiol. 2005;43:3636–3641. doi: 10.1128/JCM.43.8.3636-3641.2005. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF79] 79.Multiplex PCR reveals a high prevalence of multiple pathogens in traveller's diarrhoea in children. Pouletty M, De Pontual L, Lopez M, et al. Arch Dis Child. 2019;104:141–146. doi: 10.1136/archdischild-2017-314327. [DOI] [PubMed] [Google Scholar]

[REF80] 80.Potentially pathogenic organisms in stools and their association with acute diarrheal illness in children aged <2 years. Mihala G, Ware RS, Lambert SB, et al. J Pediatric Infect Dis Soc. 2022;11:199–206. doi: 10.1093/jpids/piab130. [DOI] [PubMed] [Google Scholar]

[REF81] 81.Etiology of acute diarrhea in Tunisian children with emphasis on diarrheagenic Escherichia coli: prevalence and identification of E. coli virulence markers. Ben Salem-Ben NI, Hassine ZM, Hassine F, Sdir-Loulizi K, Ben SM, Aouni M, Mzoughi R. https://pmc.ncbi.nlm.nih.gov/articles/PMC4401059/#abstract1. Iran J Public Health. 2014;43:947–960. [PMC free article] [PubMed] [Google Scholar]

[REF82] 82.Giardia and Cryptosporidium in children with diarrhea, Kufra, Libya, a North African migration route city. Saaed FM, Ongerth JE. Int J Hyg Environ Health. 2019;222:840–846. doi: 10.1016/j.ijheh.2019.04.006. [DOI] [PubMed] [Google Scholar]

[REF83] 83.Etiology and epidemiology of diarrhea in hospitalized children from low income country: a matched case-control study in Central African Republic. Breurec S, Vanel N, Bata P, et al. PLoS Negl Trop Dis. 2016;10:0. doi: 10.1371/journal.pntd.0004283. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF84] 84.Evaluation of the BioFire FilmArray® GastrointestinalPanel in a Midwestern Academic Hospital. Murphy CN, Fowler RC, Iwen PC, Fey PD. Eur J Clin Microbiol Infect Dis. 2017;36:747–754. doi: 10.1007/s10096-016-2858-7. [DOI] [PubMed] [Google Scholar]

[REF85] 85.Evaluation of the xTAG gastrointestinal pathogen panel assay for the detection of enteric pathogens in Kuwait. Albert MJ, Rotimi VO, Iqbal J, Chehadeh W. Med Princ Pract. 2016;25:472–476. doi: 10.1159/000447698. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF86] 86.Modeling solutions for microbial water contamination in the global south for public health protection. Izah SC, Ogwu MC. Front Microbiol. 2025;16:1504829. doi: 10.3389/fmicb.2025.1504829. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF87] 87.Prevalence and diversity of intestinal parasites in children around the world. D'Alessandro AB, Pedreira LE, Farias GS. Rev Gest Soc Ambient. 2024;18:1–12. [Google Scholar]

[REF88] 88.The global prevalence of Cyclospora cayetanensis infection: a systematic review, meta-analysis, and meta-regression. Chen Y, Qin Z, Li J, Xiao L, Zhang L. Acta Trop. 2024;253:107175. doi: 10.1016/j.actatropica.2024.107175. [DOI] [PubMed] [Google Scholar]

[REF89] 89.Spatial and temporal trends in HIV/AIDS burden among South Asian countries from 1990 to 2021: a systematic examination of the Global Burden of Disease study 2021. Akashanand Akashanand, Khatib MN, Serhan HA, et al. HIV Med. 2025;26:734–747. doi: 10.1111/hiv.70003. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF90] 90.Sources and prevalence of Cyclospora cayetanensis in southeastern US growing environments. Kahler AM, Hofstetter J, Arrowood M, et al. J Food Prot. 2024;87:100309. doi: 10.1016/j.jfp.2024.100309. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF91] 91.Global prevalence of Giardia infection in nonhuman mammalian hosts: a systematic review and meta-analysis of five million animals. Hatam-Nahavandi K, Ahmadpour E, Badri M, Eslahi AV, Anvari D, Carmena D, Xiao L. PLoS Negl Trop Dis. 2025;19:0. doi: 10.1371/journal.pntd.0013021. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF92] 92.The epidemiology and burden of injury in countries of the Association of Southeast Asian Nations (ASEAN), 1990-2021: findings from the Global Burden of Disease Study. van der Lubbe SC, Chong LS, Hay SI, et al. https://www.thelancet.com/action/showPdf?pii=S2468-2667%2825%2900069-6. Lancet Public Health. 2025;10:456–466. doi: 10.1016/S2468-2667(25)00069-6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF93] 93.Prevalence of intestinal parasites, with emphasis on the molecular epidemiology of Giardia duodenalis and Blastocystis sp., in the Paranaguá Bay, Brazil: a community survey. Seguí R, Muñoz-Antoli C, Klisiowicz DR, et al. Parasit Vectors. 2018;11:1–19. doi: 10.1186/s13071-018-3054-7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF94] 94.Multilocus genotyping of Giardia duodenalis in mostly asymptomatic indigenous people from the Tapirapé Tribe, Brazilian Amazon. Köster PC, Malheiros AF, Shaw JJ, et al. Pathogens. 2021;10:206. doi: 10.3390/pathogens10020206. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF95] 95.Parasitic infections among patients hospitalized in the Tropical and Parasitic Clinic of Poznan University of Medical Sciences, Poland between 2015 and 2018. Is there a relationship between protozoa infection and gastrointestinal symptoms? Pielok ŁA, Kłudkowska M, Frąckowiak K, Stefaniak J. Prz Gastroenterol. 2022;17:310–315. doi: 10.5114/pg.2022.121823. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF96] 96.Cryptosporidium and Giardia in Africa: current and future challenges. Squire SA, Ryan U. Parasit Vectors. 2017;10:1–32. doi: 10.1186/s13071-017-2111-y. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF97] 97.Krumrie S. Glasgow: University of Glasgow; 2022. Molecular epidemiology of Giardia duodenalis in the high-income world University of Glasgow [Master's Thesis] [Google Scholar]

[REF98] 98.Molecular epidemiology of Cryptosporidium parvum and Giardia lamblia in different water bodies, soil, and vegetables in Pakistan. Abbas Z, Khan MK, Abbas RZ, et al. Health Secur. 2022;20:308–320. doi: 10.1089/hs.2021.0118. [DOI] [PubMed] [Google Scholar]

[REF99] 99.Waterborne transmission of protozoan parasites: a review of worldwide outbreaks - an update 2017-2022. Bourli P, Eslahi AV, Tzoraki O, Karanis P. J Water Health. 2023;21:1421–1447. doi: 10.2166/wh.2023.094. [DOI] [PubMed] [Google Scholar]

[REF100] 100.Cryptosporidium infections in Nepal: a narrative review. Dhakal P, Li J, Zhang L. One Health Bull. 2023;3:13. [Google Scholar]

[REF101] 101.Molecular methods for diagnosis of Entamoeba histolytica in a clinical setting: an overview. Paul J, Srivastava S, Bhattacharya S. Exp Parasitol. 2007;116:35–43. doi: 10.1016/j.exppara.2006.11.005. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF102] 102.A scoping review of the detection, epidemiology and control of Cyclospora cayetanensis with an emphasis on produce, water and soil. Totton SC, O'Connor AM, Naganathan T, Martinez BA, Vriezen ER, Torrence ME, Sargeant JM. Epidemiol Infect. 2021;149:0. doi: 10.1017/S0950268821000200. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF103] 103.In pediatric gastroenteritis: the presence of Helicobacter pylori prevalence of Entamoeba histolytica, Giardia intestinalis and Cryptosporidium spp. Çelebi D, Çelebi Ö. https://dergipark.org.tr/en/download/article-file/1945124 Dicle Tıp Dergisi. 2021;48:425–430. [Google Scholar]

[REF104] 104.Epidemiology of Blastocystis infection: a review of data from Poland in relation to other reports. Rudzińska M, Sikorska K. Pathogens. 2023;12:1050. doi: 10.3390/pathogens12081050. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF105] 105.Blastocystis spp. and other intestinal parasites in Polish soldiers deployed to Lebanon and Iraq. Kosik-Bogacka DI, Korzeniewski K, Łanocha-Arendarczyk N, Korycińska J, Lepczyńska M, Dzika E, Marchelek-Myśliwiec M. Pathogens. 2024;13:271. doi: 10.3390/pathogens13030271. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF106] 106.Christopher JP. Georgia: University of Georgia; 2021. Parasite: Host, and Environmental Traits Predict the Zoonotic Risk of Protozoan Parasites [Thesis] [Google Scholar]

[REF107] 107.Molecular-based diagnosis of Entamoeba histolytica infection. Huston CD, Haque R, Petri WA Jr. Expert Rev Mol Med. 1999;1:1–11. doi: 10.1017/S1462399499000599. [DOI] [PubMed] [Google Scholar]

[REF108] 108.Clinical molecular and genomic epidemiology of Morganella morganii in China. Xiang G, Lan K, Cai Y, et al. Front Microbiol. 2021;12:744291. doi: 10.3389/fmicb.2021.744291. [DOI] [PMC free article] [PubMed] [Google Scholar]

[REF109] 109.Development of a molecular serotyping scheme for Morganella morganii. Liu B, Guo X, Wang J, et al. Front Microbiol. 2021;12:791165. doi: 10.3389/fmicb.2021.791165. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Burden and Distribution of Protozoan Pathogens in Diarrhea Cases Worldwide: A Systematic Review and Meta-Analysis, 1999-2024

Joseph B Suleiman

Maryam Azlan

Abstract

Introduction and background

Table 1. Global prevalence and health risks of enteric protozoa and related organisms.

Review

Figure 1. Summary of the procedure for identifying and selecting relevant articles.

Table 2. Distribution of global protozoan isolates from 1999-2024.

Figure 2. Overall prevalence of global protozoan isolates in diarrhea cases.

Figure 3. Subgroup prevalence of global protozoan isolates in diarrhea cases.

Figure 4. Funnel plot for global protozoan isolates in diarrhea cases.

Table 3. Pooled data on the prevalence of protozoan isolates in Asia.

Table 4. Pooled data on the prevalence of protozoan isolates in the Americas.

Table 5. Pooled data on the prevalence of protozoan isolates in Europe.

Table 6. Pooled data on the prevalence of protozoan isolates in Africa.

Table 7. Total pooled prevalence estimates for global protozoan isolates.

Figure 5. Subgroup prevalence of global protozoan isolates in diarrhea cases based on detection methods.

Figure 6. Subgroup prevalence of global protozoan isolates in diarrhea cases based on year of publication.

Figure 7. Prevalence of total protozoa vs. total pathogens.

Figure 8. Prevalence of protozoa vs. year of publication.

Figure 9. Map showing the distribution of global protozoan isolates across continents.

Conclusions

Acknowledgments

Appendices

Table 8. Quality of included studies by JBI critical appraisal checklist for studies reporting prevalence data.

Table 9. Distribution of various protozoan species in diarrhea cases from 1999-2024.

Disclosures

Author Contributions

References

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

Burden and Distribution of Protozoan Pathogens in Diarrhea Cases Worldwide: A Systematic Review and Meta-Analysis, 1999-2024

Joseph B Suleiman

Maryam Azlan

Abstract

Introduction and background

Table 1. Global prevalence and health risks of enteric protozoa and related organisms.

Review

Figure 1. Summary of the procedure for identifying and selecting relevant articles.

Table 2. Distribution of global protozoan isolates from 1999-2024.

Figure 2. Overall prevalence of global protozoan isolates in diarrhea cases.

Figure 3. Subgroup prevalence of global protozoan isolates in diarrhea cases.

Figure 4. Funnel plot for global protozoan isolates in diarrhea cases.

Table 3. Pooled data on the prevalence of protozoan isolates in Asia.

Table 4. Pooled data on the prevalence of protozoan isolates in the Americas.

Table 5. Pooled data on the prevalence of protozoan isolates in Europe.

Table 6. Pooled data on the prevalence of protozoan isolates in Africa.

Table 7. Total pooled prevalence estimates for global protozoan isolates.

Figure 5. Subgroup prevalence of global protozoan isolates in diarrhea cases based on detection methods.

Figure 6. Subgroup prevalence of global protozoan isolates in diarrhea cases based on year of publication.

Figure 7. Prevalence of total protozoa vs. total pathogens.

Figure 8. Prevalence of protozoa vs. year of publication.

Figure 9. Map showing the distribution of global protozoan isolates across continents.

Conclusions

Acknowledgments

Appendices

Table 8. Quality of included studies by JBI critical appraisal checklist for studies reporting prevalence data.

Table 9. Distribution of various protozoan species in diarrhea cases from 1999-2024.

Disclosures

Author Contributions

References

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases