{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T06:31:55Z","timestamp":1792737115977,"version":"4.5.0"},"reference-count":38,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2023,3,31]],"date-time":"2023-03-31T00:00:00Z","timestamp":1680220800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"DOI":"10.13039\/100014035","name":"Armed Forces Health Surveillance Branch","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100014035","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:p>Diarrheal diseases are a leading cause of mortality and morbidity, disproportionally affecting persons residing in low and middle-income countries. Accessing high-resolution surveillance data to understand community-level etiology and risk remains challenging, particularly in remote and resource limited populations. A multi-year prospective cohort study was conducted in two rural and two peri-urban villages in Cambodia from 2012 to 2018 to describe the epidemiology and etiology of acute diarrheal diseases within the population. Suspected diarrheal episodes among participants were self-reported or detected via routine weekly household visits. Fresh stool and fecal swabs were tested, and acute-illness and follow-up participant questionnaires collected. Of 5027 enrolled participants, 1450 (28.8%) reported at least one diarrheal incident. A total of 4266 individual diarrhea case events were recorded. Diarrhea incidence rate was calculated to be 281.5 persons per 1000 population per year, with an event rate of 664.3 individual diarrhea events occurring per 1000 population per year. Pathogenic <jats:italic>Escherichia coli<\/jats:italic>, <jats:italic>Aeromonas spp<\/jats:italic>., and <jats:italic>Plesiomonas shigelloides<\/jats:italic> were the most prevalent bacterial infections identified. Hookworm and <jats:italic>Strongyloides stercoralis<\/jats:italic> were the predominant helminth species, while <jats:italic>Blastocystis hominis<\/jats:italic> and <jats:italic>Giardia lamblia<\/jats:italic> were the predominant protozoan species found. Norovirus genotype 2 was the predominant virus identified. Mixed infections of two or more pathogens were detected in 36.2% of positive cases. Risk analyses identified unemployed status increased diarrhea risk by 63% (HR = 1.63 [95% CI 1.46, 1.83]). Individuals without access to protected water sources or sanitation facilities were 59% (HR = 1.59 [95% CI 1.49, 1.69]) and 19% (HR = 1.19 [95% CI 1.12, 1.28]) greater risk of contracting diarrhea, respectively. Patient-level surveillance data captured in this long-term study has generated a unique spatiotemporal profile of diarrheal disease in Cambodia. Understanding etiologies, together with associated epidemiological and community-level risk, provides valuable public health insight to support effective planning and delivery of appropriate local population-targeted interventions.<\/jats:p>","DOI":"10.1371\/journal.pone.0283871","type":"journal-article","created":{"date-parts":[[2023,3,31]],"date-time":"2023-03-31T18:13:23Z","timestamp":1680286403000},"page":"e0283871","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":8,"title":["Etiology and risk factors for diarrheal disease amongst rural and peri-urban populations in Cambodia, 2012\u20132018"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2922-3622","authenticated-orcid":true,"given":"Gerard C.","family":"Kelly","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agus","family":"Rachmat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert D.","family":"Hontz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marvin J.","family":"Sklar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Long Khanh","family":"Tran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4640-0945","authenticated-orcid":true,"given":"Chonthida","family":"Supaprom","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Malen","family":"Luy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sin","family":"Lina","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9731-6559","authenticated-orcid":true,"given":"Michael J.","family":"Gregory","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heng","family":"Sopheab","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John S.","family":"Brooks","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ian W.","family":"Sutherland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen S.","family":"Corson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7361-5917","authenticated-orcid":true,"given":"Andrew G.","family":"Letizia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,3,31]]},"reference":[{"key":"pone.0283871.ref001","author":"WHO","year":"2020"},{"issue":"10258","key":"pone.0283871.ref002","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1016\/S0140-6736(20)30925-9","article-title":"Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u20132019: a systematic analysis for the Global Burden of Disease Study 2019","volume":"396","author":"T Vos","year":"2020","journal-title":"The Lancet"},{"issue":"11","key":"pone.0283871.ref003","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1016\/S1473-3099(18)30362-1","article-title":"Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016","volume":"18","author":"C Troeger","year":"2018","journal-title":"The Lancet Infectious Diseases"},{"issue":"9","key":"pone.0283871.ref004","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":"C Troeger","year":"2017","journal-title":"The Lancet Infectious Diseases"},{"issue":"1","key":"pone.0283871.ref005","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1186\/s12889-022-12515-3","article-title":"The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: evidence from the global burden of disease study","volume":"22","author":"DK Behera","year":"2022","journal-title":"BMC Public Health"},{"key":"pone.0283871.ref006","author":"UNICEF WHO","year":"2013"},{"issue":"5","key":"pone.0283871.ref007","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1097\/QCO.0b013e32834aa13a","article-title":"Defining the causes of diarrhea: novel approaches","volume":"24","author":"DJ Operario","year":"2011","journal-title":"Curr Opin Infect Dis"},{"issue":"1","key":"pone.0283871.ref008","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1177\/2049936117744429","article-title":"The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management","volume":"5","author":"M Mokomane","year":"2018","journal-title":"Therapeutic Advances in Infectious Disease"},{"issue":"9409","key":"pone.0283871.ref009","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1016\/S0140-6736(04)15599-2","article-title":"Diarrhoea in children: an interface between developing and developed countries","volume":"363","author":"N Thapar","year":"2004","journal-title":"Lancet (London, England)."},{"issue":"3","key":"pone.0283871.ref010","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1053\/j.spid.2004.05.008","article-title":"Acute, infectious diarrhea among children in developing countries","volume":"15","author":"LJ Podewils","year":"2004","journal-title":"Semin Pediatr Infect Dis"},{"issue":"9","key":"pone.0283871.ref011","doi-asserted-by":"crossref","first-page":"e019699","DOI":"10.1136\/bmjopen-2017-019699","article-title":"Epidemiology, aetiology and seasonality of infectious diarrhoea in adult outpatients through active surveillance in Shanghai, China, 2012\u20132016: a cross-sectional study","volume":"8","author":"X-H Gong","year":"2018","journal-title":"BMJ Open"},{"key":"pone.0283871.ref012","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.ijid.2018.02.022","article-title":"Bacterial pathogen spectrum of acute diarrheal outpatients in an urbanized rural district in Southwest China","volume":"70","author":"Y Zhou","year":"2018","journal-title":"International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases"},{"issue":"4","key":"pone.0283871.ref013","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1097\/INF.0b013e3181fb6f82","article-title":"Etiology of Diarrhea in Young Children and Patterns of Antibiotic Resistance in Cambodia.","volume":"30","author":"CY Meng","year":"2011","journal-title":"The Pediatric Infectious Disease Journal"},{"issue":"1","key":"pone.0283871.ref014","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1186\/1471-2458-12-220","article-title":"Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review","volume":"12","author":"CL Fischer Walker","year":"2012","journal-title":"BMC Public Health"},{"key":"pone.0283871.ref015","unstructured":"GADM. Database of Global Administrative Areas [cited 2022 March 3]. Available from: https:\/\/gadm.org\/."},{"key":"pone.0283871.ref016","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/1471-2334-5-8","article-title":"Detection of virulence genes in Malaysian Shigella species by multiplex PCR assay","volume":"5","author":"KL Thong","year":"2005","journal-title":"BMC Infect Dis"},{"issue":"12","key":"pone.0283871.ref017","doi-asserted-by":"crossref","first-page":"5549","DOI":"10.1128\/JCM.42.12.5549-5557.2004","article-title":"Differentiation of Campylobacter coli, Campylobacter jejuni, Campylobacter lari, and Campylobacter upsaliensis by a multiplex PCR developed from the nucleotide sequence of the lipid A gene lpxA","volume":"42","author":"JD Klena","year":"2004","journal-title":"Journal of clinical microbiology"},{"issue":"2","key":"pone.0283871.ref018","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1128\/JCM.43.2.755-760.2005","article-title":"Detection and characterization of diarrheagenic Escherichia coli from young children in Hanoi, Vietnam","volume":"43","author":"TV Nguyen","year":"2005","journal-title":"Journal of clinical microbiology"},{"issue":"2","key":"pone.0283871.ref019","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1016\/j.jviromet.2008.08.004","article-title":"One-step quantitative RT-PCR for the detection of rotavirus in acute gastroenteritis","volume":"153","author":"SQ Zeng","year":"2008","journal-title":"Journal of virological methods"},{"key":"pone.0283871.ref020","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1186\/1471-2334-6-69","article-title":"Detection of Norovirus genogroup I and II by multiplex real-time RT- PCR using a 3\u2019-minor groove binder-DNA probe","volume":"6","author":"M Hoehne","year":"2006","journal-title":"BMC Infect Dis"},{"issue":"7","key":"pone.0283871.ref021","doi-asserted-by":"crossref","first-page":"121","DOI":"10.21037\/atm.2018.02.12","article-title":"Time-varying covariates and coefficients in Cox regression models.","volume":"6","author":"Z Zhang","year":"2018","journal-title":"Annals of translational medicine"},{"issue":"1","key":"pone.0283871.ref022","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1093\/ije\/dyu222","article-title":"Modelling recurrent events: a tutorial for analysis in epidemiology","volume":"44","author":"LD Amorim","year":"2014","journal-title":"International Journal of Epidemiology"},{"issue":"3","key":"pone.0283871.ref023","doi-asserted-by":"crossref","first-page":"e255","DOI":"10.1016\/S2214-109X(18)30045-7","article-title":"Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years","volume":"6","author":"C Troeger","year":"2018","journal-title":"The Lancet Global Health"},{"issue":"5","key":"pone.0283871.ref024","doi-asserted-by":"crossref","first-page":"e568","DOI":"10.1016\/S2214-109X(19)30076-2","article-title":"The incidence, aetiology, and adverse clinical consequences of less severe diarrhoeal episodes among infants and children residing in low-income and middle-income countries: a 12-month case-control study as a follow-on to the Global Enteric Multicenter Study (GEMS).","volume":"7","author":"KL Kotloff","year":"2019","journal-title":"The Lancet Global Health"},{"issue":"7","key":"pone.0283871.ref025","doi-asserted-by":"crossref","first-page":"e758","DOI":"10.1016\/S2214-109X(18)30283-3","article-title":"Morbidity, mortality, and long-term consequences associated with diarrhoea from Cryptosporidium infection in children younger than 5 years: a meta-analyses study","volume":"6","author":"IA Khalil","year":"2018","journal-title":"Lancet Glob Health"},{"issue":"4","key":"pone.0283871.ref026","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1016\/S0188-4409(02)00379-X","article-title":"Magnitude and Impact of Diarrheal Diseases","volume":"33","author":"RL Guerrant","year":"2002","journal-title":"Archives of Medical Research"},{"issue":"3","key":"pone.0283871.ref027","doi-asserted-by":"crossref","first-page":"e230","DOI":"10.1016\/S2214-109X(18)30047-0","article-title":"Exploring the broader consequences of diarrhoeal diseases on child health","volume":"6","author":"TF Wierzba","year":"2018","journal-title":"The Lancet Global Health"},{"issue":"1","key":"pone.0283871.ref028","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1186\/s12879-020-4770-0","article-title":"Prevalence of diarrhoea and associated risk factors among children under five years old in Pader District, northern Uganda","volume":"20","author":"S Omona","year":"2020","journal-title":"BMC Infectious Diseases"},{"issue":"10","key":"pone.0283871.ref029","doi-asserted-by":"crossref","DOI":"10.1002\/14651858.CD004794.pub3","article-title":"Interventions to improve water quality for preventing diarrhoea.","author":"TF Clasen","year":"2015","journal-title":"Cochrane Database of Systematic Reviews"},{"issue":"7597","key":"pone.0283871.ref030","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1136\/bmj.39118.489931.BE","article-title":"Interventions to improve water quality for preventing diarrhoea: systematic review and meta-analysis","volume":"334","author":"T Clasen","year":"2007","journal-title":"BMJ"},{"issue":"1","key":"pone.0283871.ref031","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1016\/j.trstmh.2004.02.008","article-title":"Diarrhoea and garbage disposal in Salvador, Brazil","volume":"99","author":"RF Rego","year":"2005","journal-title":"Transactions of the Royal Society of Tropical Medicine and Hygiene"},{"issue":"1","key":"pone.0283871.ref032","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1097\/01.ede.0000187621.41373.0a","article-title":"Risk Factors for Diarrhea among Children in an Industrialized Country","volume":"17","author":"S Ethelberg","year":"2006","journal-title":"Epidemiology"},{"issue":"04","key":"pone.0283871.ref033","first-page":"43","article-title":"Prevalence of diarrhoea and risk factors among children under five years old in Mbour, Senegal: a cross-sectional study","volume":"06","author":"S Thiam","year":"2017","journal-title":"Infectious Diseases of Poverty"},{"issue":"7","key":"pone.0283871.ref034","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1016\/j.trstmh.2012.02.001","article-title":"Factors associated with rotavirus diarrhoea in children living in a socially diverse urban centre in Brazil","volume":"106","author":"A Strina","year":"2012","journal-title":"Transactions of the Royal Society of Tropical Medicine and Hygiene"},{"issue":"8","key":"pone.0283871.ref035","doi-asserted-by":"crossref","first-page":"1098","DOI":"10.1016\/j.ijheh.2019.08.006","article-title":"Effectiveness of a community-based water, sanitation, and hygiene (WASH) intervention in reduction of diarrhoea among under-five children: Evidence from a repeated cross-sectional study (2007\u20132015) in rural Bangladesh","volume":"222","author":"NC Dey","year":"2019","journal-title":"International journal of hygiene and environmental health"},{"issue":"1","key":"pone.0283871.ref036","doi-asserted-by":"crossref","first-page":"977","DOI":"10.1186\/1471-2458-13-977","article-title":"Association of food-hygiene practices and diarrhea prevaylence among Indonesian young children from low socioeconomic urban areas.","volume":"13","author":"R Agustina","year":"2013","journal-title":"BMC Public Health"},{"issue":"12","key":"pone.0283871.ref037","doi-asserted-by":"crossref","first-page":"126001","DOI":"10.1289\/EHP6181","article-title":"Understanding the Impact of Rainfall on Diarrhea: Testing the Concentration-Dilution Hypothesis Using a Systematic Review and Meta-Analysis","volume":"128","author":"ANM Kraay","year":"2020","journal-title":"Environmental Health Perspectives"},{"key":"pone.0283871.ref038","article-title":"Foodborne outbreak investigation in a rural pagoda, Kampong Cham Province, Cambodia, August 2016","author":"B So","journal-title":"9th TEPHINET Bi-regional; Lao"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0283871","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,3,31]],"date-time":"2023-03-31T18:13:51Z","timestamp":1680286431000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0283871"}},"subtitle":[],"editor":[{"given":"Khin","family":"Thet Wai","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2023,3,31]]},"references-count":38,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2023,3,31]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0283871","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,3,31]]}}}