title: Gastroenteritis attributable to 16 enteropathogens in children attending day care: significant effects of rotavirus, norovirus, astrovirus, Cryptosporidium and Giardia.
abstract: BACKGROUND
  Children attending day care experience substantial gastrointestinal morbidity due to circulating seasonal enteropathogens in the day-care environment. The lack of a distinct clinical presentation of gastroenteritis (GE) in these children, in combination with the high diversity of enteropathogenic agents, complicates the assessment of the individual contributions of enteropathogens that may cause GE. We aimed to estimate the proportion of day-care attendees experiencing GE that could be attributed to a range of enteropathogens circulating in day care in the Netherlands in 2010-2013.
  
  
  METHODS
  Using time-series data from a national laboratory-based and syndrome-based surveillance system in Dutch day-care centers and generalized estimating equation analysis, we modelled the variation in prevalence of 16 enteropathogens of bacterial (8), viral (5) and parasitic origin (3) circulating in day care to the variation of GE incidence among children attending day care.
  
  
  RESULTS
  Rotavirus, norovirus, astrovirus, Giardia and Cryptosporidium were significantly associated with GE morbidity among day-care attendees in our time-series analysis. Together, these enteropathogens accounted for 39% of the GE morbidity: 11% by rotavirus, 10% by norovirus, 8% by Giardia, 7% by astrovirus and 3% by Cryptosporidium.
  
  
  CONCLUSIONS
  We demonstrate that circulating viruses and parasites, rather than bacteria, contribute to seasonal GE experienced by children in day care.
authors.affiliation: From the *Center for Infectious Disease Control (Epidemiology and Surveillance Unit), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; †Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; ‡Center for Infectious Disease Control (Laboratory for Infectious Diseases and Perinatal Screening), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; §Laboratory for Infectious Diseases, Department of Research and Development, Groningen, The Netherlands; ¶Institute of Public Health, United Arab Emirates University, AlAin, United Arab Emirates; and ‖Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Remko
authors.initials: R
authors.lastname: Enserink
authors.forename: Cees
authors.initials: C
authors.lastname: van den Wijngaard
authors.forename: Patricia
authors.initials: P
authors.lastname: Bruijning-Verhagen
authors.forename: Liselotte
authors.initials: L
authors.lastname: van Asten
authors.forename: Lapo
authors.initials: L
authors.lastname: Mughini-Gras
authors.forename: Erwin
authors.initials: E
authors.lastname: Duizer
authors.forename: Titia
authors.initials: T
authors.lastname: Kortbeek
authors.forename: Rianne
authors.initials: R
authors.lastname: Scholts
authors.forename: Nico
authors.initials: N
authors.lastname: Nagelkerke
authors.forename: Henriette A
authors.initials: HA
authors.lastname: Smit
authors.forename: Mirjam
authors.initials: M
authors.lastname: Kooistra-Smid
authors.forename: Wilfrid
authors.initials: W
authors.lastname: van Pelt
mesh_terms: D000818:Animals; D001419:Bacteria / Q000145:classification / Q000302:isolation & purification; D001424:Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology; D002656:Child Day Care Centers; D002675:Child, Preschool; D005260:Female; D005759:Gastroenteritis / Q000453:epidemiology* / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007411:Intestinal Diseases, Parasitic / Q000453:epidemiology* / Q000469:parasitology; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D010271:Parasites / Q000145:classification / Q000302:isolation & purification; D015995:Prevalence; D014777:Virus Diseases / Q000453:epidemiology* / Q000821:virology; D014780:Viruses / Q000145:classification / Q000302:isolation & purification