{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T19:35:26Z","timestamp":1790796926725,"version":"4.1.0"},"reference-count":33,"publisher":"Oxford University Press (OUP)","issue":"9","funder":[{"DOI":"10.13039\/100000030","name":"Centers for Disease Control and Prevention","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000030","id-type":"DOI","asserted-by":"publisher"}]},{"name":"the Emory Center for AIDS Research"},{"name":"Atlanta VAMC"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,11,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Acute gastroenteritis (AGE) burden, etiology, and severity in adults is not well characterized. We implemented a multisite AGE surveillance platform in 4 Veterans Affairs Medical Centers (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California), collectively serving &amp;gt;320 000 patients annually.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>From 1 July 2016 to 30 June 2018, we actively identified inpatient AGE case patients and non-AGE inpatient controls through prospective screening of admitted patients and passively identified outpatients with AGE through stool samples submitted for clinical diagnostics. We abstracted medical charts and tested stool samples for 22 pathogens by means of multiplex gastrointestinal polymerase chain reaction panel followed by genotyping of norovirus- and rotavirus-positive samples. We determined pathogen-specific prevalence, incidence, and modified Vesikari severity scores.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>We enrolled 724 inpatients with AGE, 394 non-AGE inpatient controls, and 506 outpatients with AGE. Clostridioides difficile and norovirus were most frequently detected among inpatients (for AGE case patients vs controls: C. difficile, 18.8% vs 8.4%; norovirus, 5.1% vs 1.5%; P &amp;lt; .01 for both) and outpatients (norovirus, 10.7%; C. difficile, 10.5%). The incidence per 100 000 population was highest among outpatients (AGE, 2715; C. difficile, 285; norovirus, 291) and inpatients \u226565 years old (AGE, 459; C. difficile, 91; norovirus, 26). Clinical severity scores were highest for inpatient norovirus, rotavirus, and Shigella\/enteroinvasive Escherichia coli cases. Overall, 12% of inpatients with AGE had intensive care unit stays, and 2% died; 3 deaths were associated with C. difficile and 1 with norovirus. C. difficile and norovirus were detected year-round with a fall\/winter predominance.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>C. difficile and norovirus were leading AGE pathogens in outpatient and hospitalized US veterans, resulting in severe disease. Clinicians should remain vigilant for bacterial and viral causes of AGE year-round.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/cid\/ciaa806","type":"journal-article","created":{"date-parts":[[2020,6,22]],"date-time":"2020-06-22T19:42:19Z","timestamp":1592854939000},"page":"e2729-e2738","source":"Crossref","is-referenced-by-count":33,"title":["Incidence, Etiology, and Severity of Acute Gastroenteritis Among Prospectively Enrolled Patients in 4 Veterans Affairs Hospitals and Outpatient Centers, 2016\u20132018"],"prefix":"10.1093","volume":"73","author":[{"given":"Cristina V","family":"Cardemil","sequence":"first","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neha","family":"Balachandran","sequence":"additional","affiliation":[{"name":"Cherokee Nation Assurance, Arlington, Virginia, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anita","family":"Kambhampati","sequence":"additional","affiliation":[{"name":"Cherokee Nation Assurance, Arlington, Virginia, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott","family":"Grytdal","sequence":"additional","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca M","family":"Dahl","sequence":"additional","affiliation":[{"name":"Maximus Federal, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria C","family":"Rodriguez-Barradas","sequence":"additional","affiliation":[{"name":"Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Blanca","family":"Vargas","sequence":"additional","affiliation":[{"name":"Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David O","family":"Beenhouwer","sequence":"additional","affiliation":[{"name":"VA Greater Los Angeles Healthcare System, Los Angeles, California, USA"},{"name":"David Geffen School of Medicine at UCLA, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen V","family":"Evangelista","sequence":"additional","affiliation":[{"name":"VA Greater Los Angeles Healthcare System, Los Angeles, California, USA"},{"name":"David Geffen School of Medicine at UCLA, Los Angeles, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent C","family":"Marconi","sequence":"additional","affiliation":[{"name":"Atlanta VA Medical Center, Atlanta, Georgia, USA"},{"name":"Emory University School of Medicine, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn L","family":"Meagley","sequence":"additional","affiliation":[{"name":"Atlanta VA Medical Center, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheldon T","family":"Brown","sequence":"additional","affiliation":[{"name":"James J. Peters VA Medical Center, Bronx, New York, USA"},{"name":"Icahn School of Medicine at Mt Sinai, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrienne","family":"Perea","sequence":"additional","affiliation":[{"name":"James J. Peters VA Medical Center, Bronx, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cynthia","family":"Lucero-Obusan","sequence":"additional","affiliation":[{"name":"Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, USA"},{"name":"VA Palo Alto Health Care System, Palo Alto, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Holodniy","sequence":"additional","affiliation":[{"name":"Public Health Surveillance and Research, Department of Veterans Affairs, Washington, DC, USA"},{"name":"VA Palo Alto Health Care System, Palo Alto, California, USA"},{"name":"Stanford University, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah","family":"Browne","sequence":"additional","affiliation":[{"name":"Cherokee Nation Assurance, Arlington, Virginia, contracting agency to the Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Diseases Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rashi","family":"Gautam","sequence":"additional","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael D","family":"Bowen","sequence":"additional","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan","family":"Vinj\u00e9","sequence":"additional","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Umesh D","family":"Parashar","sequence":"additional","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aron J","family":"Hall","sequence":"additional","affiliation":[{"name":"Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,6,15]]},"reference":[{"key":"2021110300360982900_CIT0001","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1016\/S1473-3099(17)30276-1","article-title":"Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015","volume":"17","author":"GBD Diarrhoeal Diseases Collaborators","year":"2017","journal-title":"Lancet Infect Dis"},{"key":"2021110300360982900_CIT0002","doi-asserted-by":"crossref","first-page":"16","DOI":"10.3201\/eid1701.P21101","article-title":"Foodborne illness acquired in the United States\u2014unspecified agents","volume":"17","author":"Scallan","year":"2011","journal-title":"Emerg Infect Dis"},{"key":"2021110300360982900_CIT0003","doi-asserted-by":"crossref","first-page":"466","DOI":"10.1093\/cid\/ciq163","article-title":"Increasing rates of gastroenteritis hospital discharges in US adults and the contribution of norovirus, 1996-2007","volume":"52","author":"Lopman","year":"2011","journal-title":"Clin Infect Dis"},{"key":"2021110300360982900_CIT0004","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1093\/cid\/cis386","article-title":"The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999\u20132007","volume":"55","author":"Hall","year":"2012","journal-title":"Clin Infect Dis"},{"key":"2021110300360982900_CIT0005","doi-asserted-by":"crossref","first-page":"1198","DOI":"10.3201\/eid1908.130465","article-title":"Norovirus disease in the United States","volume":"19","author":"Hall","year":"2013","journal-title":"Emerg Infect Dis"},{"key":"2021110300360982900_CIT0006","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1056\/NEJMoa1408913","article-title":"Burden of Clostridium difficile infection in the United States","volume":"372","author":"Lessa","year":"2015","journal-title":"N Engl J Med"},{"key":"2021110300360982900_CIT0007","doi-asserted-by":"crossref","first-page":"1121","DOI":"10.1056\/NEJMsa1206589","article-title":"Norovirus and medically attended gastroenteritis in U.S. children","volume":"368","author":"Payne","year":"2013","journal-title":"N Engl J Med"},{"key":"2021110300360982900_CIT0008","author":"Centers for Disease Control and Prevention"},{"key":"2021110300360982900_CIT0009","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1093\/infdis\/jis942","article-title":"Burden of norovirus gastroenteritis in the ambulatory setting\u2014United States, 2001-2009","volume":"207","author":"Gasta\u00f1aduy","year":"2013","journal-title":"J Infect Dis"},{"key":"2021110300360982900_CIT0010","first-page":"1381","article-title":"Incidence","volume":"17","author":"Hall","year":"2011","journal-title":"Emerg Infect Dis"},{"key":"2021110300360982900_CIT0011","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1128\/JCM.01535-14","article-title":"Advances in laboratory methods for detection and typing of norovirus","volume":"53","author":"Vinj\u00e9","year":"2015","journal-title":"J Clin Microbiol"},{"key":"2021110300360982900_CIT0012","doi-asserted-by":"crossref","first-page":"S592","DOI":"10.1093\/ofid\/ofz360.1488","article-title":"1624. Primary care physician knowledge, attitudes, and diagnostic testing practices for norovirus and acute gastroenteritis","volume":"6","author":"Cardemil","year":"2019","journal-title":"Open Forum Infect Dis"},{"key":"2021110300360982900_CIT0013","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1080\/14760584.2018.1510327","article-title":"Progress on norovirus vaccine research: public health considerations and future directions","volume":"17","author":"Mattison","year":"2018","journal-title":"Expert Rev Vaccines"},{"key":"2021110300360982900_CIT0014","doi-asserted-by":"crossref","first-page":"7300","DOI":"10.1016\/j.vaccine.2019.02.052","article-title":"Status of vaccine research and development for Clostridium difficile","volume":"37","author":"Riley","year":"2019","journal-title":"Vaccine"},{"key":"2021110300360982900_CIT0015","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1093\/cid\/ciz165","article-title":"Trends in incidence of norovirus-associated acute gastroenteritis in 4 Veterans Affairs Medical Center populations in the United States, 2011\u20132015","volume":"70","author":"Grytdal","year":"2020","journal-title":"Clin Infect Dis"},{"key":"2021110300360982900_CIT0016","doi-asserted-by":"crossref","first-page":"e0126733","DOI":"10.1371\/journal.pone.0126733","article-title":"Incidence of medically-attended norovirus-associated acute gastroenteritis in four Veteran\u2019s Affairs Medical Center populations in the United States, 2011\u20132012","volume":"10","author":"Grytdal","year":"2015","journal-title":"PLoS One"},{"key":"2021110300360982900_CIT0017","first-page":"ofz115","article-title":"Active surveillance for norovirus in a US Veterans Affairs patient population, Houston, Texas, 2015\u20132016","volume":"6","author":"Kambhampati","year":"2019","journal-title":"OFID"},{"key":"2021110300360982900_CIT0018","doi-asserted-by":"crossref","first-page":"2208","DOI":"10.1128\/JCM.00455-17","article-title":"Genetic and epidemiologic trends of norovirus outbreaks in the United States from 2013 to 2016 demonstrated emergence of novel GII.4 recombinant viruses","volume":"55","author":"Cannon","year":"2017","journal-title":"J Clin Microbiol"},{"key":"2021110300360982900_CIT0019","doi-asserted-by":"crossref","first-page":"790","DOI":"10.1093\/infdis\/jit254","article-title":"Etiology of viral gastroenteritis in children &lt;5 years of age in the United States, 2008-2009","volume":"208","author":"Chhabra","year":"2013","journal-title":"J Infect Dis"},{"key":"2021110300360982900_CIT0020","doi-asserted-by":"crossref","first-page":"e1560","DOI":"10.7717\/peerj.1560","article-title":"One-step multiplex real-time RT-PCR assay for detecting and genotyping wild-type group A rotavirus strains and vaccine strains (Rotarix\u00ae and RotaTeq\u00ae) in stool samples","volume":"4","author":"Gautam","year":"2016","journal-title":"PeerJ"},{"key":"2021110300360982900_CIT0021","doi-asserted-by":"crossref","first-page":"732","DOI":"10.1093\/infdis\/jiw233","article-title":"Rotavirus strain trends during the postlicensure vaccine era: United States, 2008\u20132013","volume":"214","author":"Bowen","year":"2016","journal-title":"J Infect Dis"},{"key":"2021110300360982900_CIT0022","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.ss6412a1","article-title":"Outbreaks of acute gastroenteritis transmitted by person-to-person contact, environmental contamination, and unknown modes of transmission\u2014United States, 2009\u20132013","volume":"64","author":"Wikswo","year":"2015","journal-title":"MMWR Surveill Summ"},{"key":"2021110300360982900_CIT0023","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1016\/j.idc.2017.07.012","article-title":"Norovirus infection in older adults: epidemiology, risk factors, and opportunities for prevention and control","volume":"31","author":"Cardemil","year":"2017","journal-title":"Infect Dis Clin North Am"},{"key":"2021110300360982900_CIT0024","doi-asserted-by":"crossref","first-page":"ofy175","DOI":"10.1093\/ofid\/ofy175","article-title":"Predictors of mortality among a national cohort of veterans with recurrent Clostridium difficile infection","volume":"5","author":"Appaneal","year":"2018","journal-title":"Open Forum Infect Dis"},{"key":"2021110300360982900_CIT0025","doi-asserted-by":"crossref","first-page":"e0189227","DOI":"10.1371\/journal.pone.0189227","article-title":"National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014","volume":"12","author":"Reveles","year":"2017","journal-title":"PLoS One"},{"key":"2021110300360982900_CIT0026","doi-asserted-by":"crossref","DOI":"10.15620\/cdc:82532","volume-title":"Antibiotic resistance threats in the United States, 2019","author":"Centers for Disease Control and Prevention","year":"2019"},{"key":"2021110300360982900_CIT0027","author":"Centers for Disease Control and Prevention"},{"key":"2021110300360982900_CIT0028","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1093\/cid\/ciy149","article-title":"Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)","volume":"66","author":"McDonald","year":"2018","journal-title":"Clin Infect Dis"},{"key":"2021110300360982900_CIT0029","doi-asserted-by":"crossref","first-page":"403","DOI":"10.2217\/ahe.13.37","article-title":"Clostridium difficile infection in older adults","volume":"9","author":"Jump","year":"2013","journal-title":"Aging health"},{"key":"2021110300360982900_CIT0030","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1016\/j.jinf.2014.11.012","article-title":"Clinical characteristics and genotypes of rotavirus in adults","volume":"70","author":"Anderson","year":"2015","journal-title":"J Infect"},{"key":"2021110300360982900_CIT0031","doi-asserted-by":"crossref","first-page":"e0148395","DOI":"10.1371\/journal.pone.0148395","article-title":"Incidence of norovirus and other viral pathogens that cause acute gastroenteritis (AGE) among Kaiser Permanente member populations in the United States, 2012\u20132013","volume":"11","author":"Grytdal","year":"2016","journal-title":"PLoS One"},{"key":"2021110300360982900_CIT0032","doi-asserted-by":"crossref","first-page":"S324","DOI":"10.1093\/ofid\/ofx163.763","article-title":"Trends in the burden and seasonality of rotavirus in the United States, 2000\u20132016","volume":"4","author":"Aliabadi","year":"2017","journal-title":"Open Forum Infect Dis"},{"key":"2021110300360982900_CIT0033","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1186\/s12882-018-1116-x","article-title":"Atypical cause of intractable diarrhea in a hemodialysis patient, masked by Clostridium difficile-associated diarrhea and ischemic colitis: a case report","volume":"19","author":"Higashihara","year":"2018","journal-title":"BMC Nephrol"}],"container-title":["Clinical Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/cid\/advance-article-pdf\/doi\/10.1093\/cid\/ciaa806\/33428369\/ciaa806.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/cid\/article-pdf\/73\/9\/e2729\/41060654\/ciaa806.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/cid\/article-pdf\/73\/9\/e2729\/41060654\/ciaa806.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,11,3]],"date-time":"2021-11-03T00:39:28Z","timestamp":1635899968000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/cid\/article\/73\/9\/e2729\/5862655"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,6,15]]},"references-count":33,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2020,6,15]]},"published-print":{"date-parts":[[2021,11,2]]}},"URL":"https:\/\/doi.org\/10.1093\/cid\/ciaa806","relation":{},"ISSN":["1058-4838","1537-6591"],"issn-type":[{"value":"1058-4838","type":"print"},{"value":"1537-6591","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,11,1]]},"published":{"date-parts":[[2020,6,15]]}}}