Indian Journal of Medical Microbiology xxx (xxxx) xxx

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Indian Journal of Medical Microbiology

journal homepage: www.journals.elsevier.com/indian-journal-of-medical-microbiology

Review Article

Campylobacter diarrhea in children in South Asia: A systematic review

Malathi Murugesan a, Dilip Abraham a, Prasanna Samuel a, b, Sitara SR Ajjampur a, *
a
The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
b
Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Campylobacter spp. are one of the commonest causes of diarrhea in children under five and in
Campylobacter resource poor settings also lead to malabsorption and stunting. The purpose of this systematic review was to
Gastroenteritis understand the burden of Campylobacter spp. associated diarrhea among children in the South Asian countries.
Children
Methods: This systematic review followed the PRISMA (Preferred Reporting Items for Systematic reviews and
South Asia
Diarrheal disease
Meta-Analysis) guidelines. Databases were searched with defined keywords for publications from the years
1998–2018. Data on proportion of positive samples was extracted to compare the rates of Campylobacter infection
among children (under the age of 19) from different study populations.
Results: Of the 359 publications screened, 27 eligible articles were included in this systematic review and cate-
gorized based on study design. In 8 case-control studies, Campylobacter spp. was detected more frequently among
diarrheal cases (range, 3.2–17.4%) than non-diarrheal cases (0–13%). Although there were variations in the study
population, overall, children under the age of two years experienced Campylobacter diarrhea more often than
older children. Most studies reported stool culture as the method used to detect Campylobacter spp. however
retesting using PCR-based methods significantly increased detection rates. Limited data were available on
Campylobacter species. In 4 studies that provided species data, C. jejuni (3.2–11.2%) was shown to be the most
common species, followed by C. coli.
Conclusion: In South Asia, Campylobacter spp. are one of the most common bacterial diarrheal pathogens affecting
children but there is a paucity of data on species, risk factors and attributable sources. Although a few studies
were available, the epidemiology of campylobacteriosis remains uncertain. To understand the true burden and
sources of infection, more detailed studies are needed collecting data from human, animal and environmental
sources and using both culture and genomic tools.

1. Introduction & objectives
Diarrheal diseases are a leading cause of death among children under
five in South Asia accounting for a mortality rate of 85.7 per 100,000
(based on the 2015 Global Burden of Disease, GBD, estimates) [1].
Campylobacter spp. were found to cause 6.2% (95% CI 1.7 to 12.5) of all
diarrheal deaths in children under five worldwide and in South Asia,
have been ranked as one among the top five leading causes of diarrheal
deaths in this age group [2,3]. The genus Campylobacter has 26 species
and ~90% of human infections are associated with a single species
namely, Campylobacter jejuni. Other species also associated with human
disease include Campylobacter coli (5%) followed by C. lari, C. upsaliensis
and C. fetus. Campylobacter infections occur more commonly in young
children in developing countries however in developed countries, older
children and adults are affected. In developed countries, the most com-
mon route of transmission to humans is foodborne, through unpasteur-
ized milk, meat, and poultry products [4]. In developing countries, data
from a limited number of studies indicate that transmission can poten-
tially be attributed to environmental contamination from feces of
chickens in households (affecting young children in those households)
and from farms and poultry markets [5].
In animal models, C. jejuni colonizes the host colon and lower intes-
tine. The pathogenesis and role of virulence factors in penetrating the
mucosa, colonization and intracellular invasion including flagellar pro-
teins, Che and CadF have been reviewed recently [6]. These interactions
lead to induction of pro-inflammatory cytokines (IL-8 and chemokines)
that in vivo, leads to local inflammation, recruitment of neutrophils and
damage to gut epithelium resulting in bloody diarrhea. C. jejuni outer

* Corresponding author. Sitara SR Ajjampur, The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore,
Tamil Nadu, India.
E-mail address: sitararao@cmcvellore.ac.in (S.S. Ajjampur).

https://doi.org/10.1016/j.ijmmb.2022.03.010
Received 22 November 2021; Received in revised form 21 March 2022; Accepted 22 March 2022
0255-0857/© 2022 Indian Association of Medical Microbiologists. Published by Elsevier B.V. All rights reserved.

Please cite this article as: Murugesan M et al., Campylobacter diarrhea in children in South Asia: A systematic review, Indian Journal of Medical
Microbiology, https://doi.org/10.1016/j.ijmmb.2022.03.010
M. Murugesan et al.
membrane lipo-oligosaccharides (LOS) modified with sialic acid residues
resemble host gangliosides dampening immunogenicity [7]. These lead
to cross-reactive antibodies than can result in post-infection autoimmune
sequelae [7]. Campylobacter infections are generally self-limiting and
infections in children present as diarrhea, abdominal pain, malaise, fever,
anorexia, nausea, vomiting, also rarely as myalgia, chills and with gross
blood in stools [8]. Although most infections are self-limiting or result in
a sub-clinical carriage, the resulting intestinal inflammation during early
childhood Campylobacter infections has been linked to environmental
enteric dysfunction (EED) [9]. The EED syndrome can result in malnu-
trition, stunting, susceptibility to further infections and poor vaccine
response in children in low to middle income countries. Two studies in
low resource settings, one a multi-country study on malnutrition and
enteric infections (MAL-ED) and the other a randomized control trial on
oral vaccines in Bangladesh (PROVIDE), found a strong association of
Campylobacter spp. infections with linear growth deficits, increased in-
testinal and systemic inflammation and increased intestinal permeability
in children under the age of 12 months [10,11]. Post-infection sequelae
due to Campylobacter spp. auto-reactive antibodies include Guillain-Barre
syndrome (GBS) and in countries where polio eradication has been suc-
cessful, are one of the commonest attributable causes of GBS [12].
The CDC laboratory criteria for diagnosis of campylobacteriosis is as
follows: ‘Probable diagnosis can be made by detection of Campylobacter
spp. using a culture-independent diagnostic test and confirmation is done
by isolation of Campylobacter from the clinical specimen’.
(https://ndc.services.cdc.gov/case-definitions/campylobacterio
sis-2015/). Isolation by culture is challenging because of its fastidious na-
ture requiring microaerophilic conditions and specialized media (Skirrow
medium, Butzler agar and Campy-BAP medium) and so is not routinely
available [13]. EIA kits detecting Campylobacter antigens and molecular
methods have increased the sensitivity of detection [14]. In studies on the
burden of enteric infections in low resource settings, molecular methods for
detection (PCR and Taqman Array Cards, TAC) significantly increased the
estimated burden of Campylobacterinfections in children [2,15].
In spite of the heavy burden of infection and post-infection sequelae,
both nutritional and immunological, appropriate treatment for campy-
lobacteriosis is difficult as it mimics other intestinal infections [3,9]. A
meta-analysis has shown that although antimicrobial treatment (the
meta-analysis included treatment with erythromycin, ciprofloxacin and
norfloxacin) shortens the duration of symptoms by 1.3 days, usage should
be restricted to cases of bacteremia or severely illness to avoid devel-
opment of antimicrobial resistance [16]. Human Campylobacter vaccines
have been designated as a ‘priority 2/high’ pathogen in the ‘Vaccines for
AMR’ report but were considered unsuitable for vaccine development
due to lack of data on attributable risk in LMIC – whether environmental
or animal sources (https://vaccinesforamr.org/). Among the vaccine
candidates developed, whole cell vaccines were not pursued due to po-
tential cross reactivity with human gangliosides but subunit vaccines
with recombinant flagellin (FlaA) and cell surface protein ACE393 were
found to be safe but only mildly immunogenic and/or not protective
during a challenge [17]. Currently, injectable glycoconjugate vaccines
are considered to have the most potential for both travelers and young
children in LMIC with the CJCV2 (C. jejuni capsular polysaccharide
HS23/36 serotype conjugated to CRM197 protein carrier) being evalu-
ated [18,19]. Studies on poultry vaccines aimed at decreasing pathogen
load thereby reducing human transmission, are ongoing. Using a DNA
prime/protein boost strategy, Meunier et al. [20] identified 4 candidates
that lead to a decreased Campylobacter load in subsequent challenge and
Nothaft et al. [21] have developed glycoconjugate vaccine candidates
that resulted in decreased colonization. In developing countries, an in-
tegrated approach of water, sanitation, and hygiene (WASH) in-
terventions along with vaccines may be required for preventing the
transmission of Campylobacter but more data are required.
In this systematic review, due to the high burden of disease in chil-
dren, our objective was to provide a comprehensive summary of
Campylobacter spp. related diarrhea in children in South Asia.
2
Indian Journal of Medical Microbiology xxx (xxxx) xxx
2. Methods
This systematic review followed the PRISMA (Preferred Reporting
Items for Systematic reviews and Meta-Analysis) guidelines [22].
Data sources: Pubmed, Embase and Cochrane databases were
searched for English language articles published from January 1st, 1998,
to the date of search, November 21st, 2018. The keywords used in all
search engines were: (Campylobacter) AND (Diarrhea OR Diarrhea OR
Gastroenteritis) AND (India OR Pakistan OR Bangladesh OR Bhutan OR
Afghanistan OR Srilanka OR Sri Lanka OR Nepal OR Maldives).
2.1. Study eligibility criteria
Inclusion criteria for studies were those that (i) included data from
children and adolescents up to 19 years of age (http://www.searo.who.
int/child_adolescent/topics/adolescent_health/en/).
(ii) were conducted in one of the South Asian countries (Afghanistan,
Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka) as
defined by the World Bank (https://data.worldbank.org/region/south
-asia/) between 1998 and 2018 (iii) were published in English and (iv)
had data on diarrhea or gastroenteritis. All observational studies that
fulfilled the afore-mentioned criteria were considered for analysis. Multi-
site studies with individual site-specific data were also included but
publications that had only secondary analysis of the data were excluded.
Studies that were designed for objectives unrelated to ascertaining
Campylobacter spp. or any entero-pathogen prevalence, but which did
report data pertaining to Campylobacter spp. associated diarrhea in
children were included and classified as cross-sectional studies for pur-
poses of the analysis.
Participants: In this systematic review, articles with data on children
and adolescents up to 19 years of age who were from South Asian
countries and diagnosed as having Campylobacter diarrhea.
Interventions: In this systematic review, no interventions were
evaluated.
Duplicate records were removed with the reference manager soft-
ware, Zotero (Zotero 5.0.60). Two reviewers independently evaluated the
articles for those that met the inclusion criteria above and discrepancies
were resolved by discussion to arrive at a consensus and any residual
conflicts were resolved by consultation with a third reviewer. When full
text articles were not available, an attempt to contact corresponding
authors was made. Eligible articles were then screened, and data
extracted independently by the two reviewers. The variables extracted
were the year of publication, sample size, age range of enrolled study
participants, duration of the study, country in which the study was car-
ried out, setting of the study (urban, rural or hospital-based), study design
(birth cohort/case-control/cross-sectional studies), diagnostic methods
used to identify Campylobacter positives (culture, EIA or PCR), the num-
ber of samples tested and the number of samples that tested positive for
Campylobacter spp. The outcome was defined as the proportion of samples
that tested positive for Campylobacter spp. calculated by the number of
samples that tested positive for Campylobacter spp. by methods described
in the study, divided by the total number of samples tested.
2.2. Statistical analysis
The prevalence data from each observational study was extracted as
proportions, and 95% confidence intervals (CI) were calculated for each
measure. The Freeman and Tukey double arcsine transformation was
used to normalize the data for the purpose of pooling estimates across
studies as some proportions were close to zero. Heterogeneity between
studies was assessed using Cochran's Q statistic, τ2 and I2 statistics, that
estimate variability between studies [23]. The DerSimonian and Laird
(DL) random-effects model was used to calculate the estimate of pooled
proportion considering the presence of significant heterogeneity. The
Microsoft Excel spreadsheet application was used to extract and compile
data, and statistical analyses were carried out in R version 4.0.2.
M. Murugesan et al.
3. Results
The literature search identified a total of 359 publications, of which
121 articles were from Pubmed, 231 were from Embase and seven were
from Cochrane databases. After duplicate records were removed, ab-
stracts of 248 articles were reviewed and 190 articles were excluded
(Fig. 1). When the full text of the 58 articles were screened for extraction
of variables, a further 33 articles were excluded, and two articles were
included by a review of the bibliography. For seven eligible articles,
despite contacting the corresponding authors, the required data could not
be obtained and thus these were excluded from the analysis. Finally, a
total of 27 articles were included and categorized into three subgroups
based on study design as cross-sectional (n ¼ 16), case-control (n ¼ 8)
and cohort (n ¼ 3) studies. A majority of the studies were from India (n ¼
12), followed by Bangladesh (n ¼ 7). Among the eligible articles, none
were from Afghanistan, Bhutan, Maldives, or Sri Lanka.
Cross sectional studies: The cross-sectional studies varied consider-
ably in study objectives, duration of study, methods of diagnosis and age
group of children enrolled (Table 1). Of the 16 studies from which data was
extracted, eight were from India [24–31], four from Bangladesh [32–35],
three from Pakistan [36–38] and one from Nepal [39]. Most cross sectional
studies conducted were hospital-based except for two studies in the
Fig. 1. PRISMA flow diagram.
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Indian Journal of Medical Microbiology xxx (xxxx) xxx
community conducted in Pakistan and Bangladesh [35,38]. The duration
of studies (three months to 18 years) and number of children enrolled (100
to >33,000) ranged widely. The definition and type of diarrhea in enrolled
cases also differed - two studies recruited children with persistent diarrhea
[32,33]; and of the remaining studies which recruited children with acute
diarrhea, some studies defined diarrhea as  3 loose stools/day in 24 h,
some as loose stools for a duration less than 14 days and most did not
describe criteria by which children with diarrhea or gastroenteritis were
included. Half the studies included only children less than five years and
the other studies included older children up to 12–14 years.
The studies showed a positivity rate for Campylobacter spp. that
ranged from 0.3% to 31.8% [32,39]. Studies conducted in India showed a
prevalence range from 4.6% [28] to 20.7% [24]. The prevalence rates of
Campylobacter in other countries in the region also showed a wide range,
example, from 1.7 to 31.8% in Bangladesh [32,33].
A meta-analysis of data from observational studies (n ¼ 18) showed a
high degree of heterogeneity between studies (τ2, 0.0038; I2, 96%, 95%
C.I. 94–97%) (Fig. 2) and the pooled estimate (weighted average pro-
portion) of Campylobacter spp. among children in South Asia in the
random effects model was 6.96% (95% CI 5.38–8.72%). Various methods
were attempted to reduce heterogeneity (data not shown) including
analysis excluding outliers in terms of sample size, study duration.
M. Murugesan et al. Indian Journal of Medical Microbiology xxx (xxxx) xxx

Table 1
Cross Sectional Studies on Campylobacter spp Infection Among Children in South Asia.
Author Location Study period Age (yrs) Study setting Method Sample size Positivity rate (%)

India
Kamalratnam et al. [26] Vellore 1990–1991 0 to 3 Hospital Culture 29 2 (6.9)
Venkataraman et al. [31] Vellore 2003a 0 to 12 Hospital Culture 262 14 (5.3)
Rajendran et al. [28] Vellore 2003–2006 0 to 5 Hospital PCR 394 18 (4.6)
Nair et al. [27] Kolkata 2007–2009 0 to 5 Hospital Culture 648 62 (9.6)
Salim et al. [30] Puducherry 2011 0 to 14 Hospital Culture/PCR 50 5 (10.0)
Ghosh et al. [25] New Delhi 2010–2012 0 to 12 Hospital Culture 350 36 (10.3)
Rathaur et al. [29] Uttarakhand 2012 0 to 12 Hospital Culture 280 17 (6.1)
Ghosh et al. [24] New Delhi 2014a 0 to 12 Hospital Culture/ELISA/PCR 585 121 (20.8)
Bangladesh
Das et al. [34] Dhaka 1993–2011 0 to 19 Hospital Culture 33,482 2551 (7.6)
Bardhan et al. [33] Dhaka 1998a 3m to 2 Hospital Culture 180 3 (1.7)
Haque et al. [35] Mirpur 1999–2002 2 to 5 Urban community Culture 893 25 (2.8)
Ashraf et al. [32] Dhaka 2002a 4m to 2 Hospital Culture 107 34 (31.8)
Pakistan
Khalil et al. [37] Lahore 1990 0 to 6 Hospital Culture 152 12 (7.9)
Ali et al. [36] Rawalpindi 2002 0 to 12 Hospital Culture 100 18 (18)
Soofi et al. [38] Karachi 2002–2003 0 to 5 Urban community Culture 8381 515 (6.1)
Nepal
Deo et al. [39] Kathmandu 2006–2008 0 to 12 Hospital Culture 645 2 (0.3)

NA - not available.
a
Year of publication mentioned, study years not available.

Case-control studies: Case-control studies (n ¼ 8) were conducted
in India (n ¼ 4), Bangladesh (n ¼ 1), Nepal (n ¼ 2) and one was the
multi-site Global Enteric Multicenter Study (GEMS) (Table 2). Seven
studies enrolled children less than 5 years of age [40–46]. Stool culture
was used as the method of detection of Campylobacter spp. in five
studies [41,42,44,46,47] and PCR was used in two studies [40,43]. In
the six hospital based studies, whether culture or PCR was used for
detection, the proportion of children with diarrhea infected with
Campylobacter spp. was higher than children with no diarrhea [40–43,
46,47]. When the risk factors for acquiring Campylobacter infection in a
rural community were studied, children less than 5 years had a two-fold
higher risk of getting infected than older children (RR ¼ 1.84) [44].
Other associated risks were households having agriculture as their main
occupation (RR ¼ 1.80) and improper hand hygiene after defecation
(RR ¼ 2.39). No other significant risk with respect to gender, defecation
practices, food habits or animal exposures were identified. Four studies
defined species by performing hippurate hydrolysis in the culture iso-
lates showing C. jejuni (3.2–11.2%) as the most common species fol-
lowed by C. coli (0–3%) [41,44,46,47].
Cohort studies: Between 1998 and 2018, three longitudinal cohort
studies following up children from birth to 1 or 2 years of age were
conducted in South Asia [Table 3]. One was conducted in Mirzapur,
Bangladesh (1993–1996) [48], one in Mirpur, Bangladesh (2008–2009)
[49] and the multi-site MAL-ED (2009–2012) study conducted in four
South Asian sites - Bangladesh, India, Nepal, and Pakistan [3]. In the
Mirzapur study, C. jejuni was isolated by stool culture in 6.2% of diarrheal
samples and 6.7% of non-diarrheal samples [48]. When stratified by age,
C. jejuni was significantly higher in diarrheal samples (9.7%) than
non-diarrheal samples (3.9%) in children less than 5 months of age, but
in children who were older than 6 months of age there was a decrease in

Fig. 2. Forest plot showing meta-analysis of proportions from cross-sectional studies on Campylobacter diarrhea among children in South Asia.

4
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Table 2
Case-Control Studies on Campylobacter spp Infection Among Children in South Asia.
Author Location Study period Age (yrs) Study setting Method Cases n Positivity Controls n Positivity
rate (%) rate (%)

Ananthan et al. [47] Chennai, India 1996 0 to 10 Hospital Culture 100 11 (11) 38 0
Albert et al. [41] Dhaka, Bangladesh 1993–1994 0 to 5 Hospital Culture 814 142 (17.4) 814 103 (12.6)
Naik & Jayaraj [46], Karnataka, India 1998c 0 to 5 Hospital Culture 697 22 (3.2) 184 0
Jain et al., [44] Lucknow, India 2002 0 to 5 Rural Culture 146 16 (10.96) NAd NAd
community
Ajjampur et al., [40] Vellore, India 2003 0 to 5 Hospital PCR 158 9 (5.7) 99 3 (3.1)
Bodhidatta et al., [42] Kathmandu, 2007–2009 3 m to 5 Hospital Culture 1200 180 (15) 1200 156 (13)
Bharatpur, Nepal
Cardemil et al., [43] Multisite, Nepal 2012–2013 0 to 1 Hospital PCR 307 29 (9.4) 358 14 (3.9)
GEMS Study Location Number AF (CI) AF (CI) AF (CI)
tested (0-1yrs) (1-2yrs) (2-5yrs)
Kotloff et al.a [45] Mirzapur, 2007–2011 0 to 5 Urban Culture/TAC 1394/877 9 (1.7–16.4) NA 0
Liu et al.b [2] Bangladesh community 12.3 (7.6–19.8) 4.5 (1.6–9.6) 2 (0.8–4.1)
Kolkata, India 1568/849 0 NA 9.9 (4.9–14.9)
9.3 (2.4–16.8) 3.6 (0–15.2) 5.4 (0–15.4)
Karachi, Pakistan 1258/788 6.70 (1.0–12.4) NA 16.1 (6.5–25.7)
7 (0–17.1) 0 0.6 (0–13.7)

NA- Not available, AF – Attributable fraction, TAC – TaqMan array card.

a
GEMS primary data.
b
GEMS TAC data.
c
Year of publication mentioned, study years not available.
d
Number of age-matched controls for children 0–5 years and their positivity is not specified.

Table 3
Longitudinal Cohort Studies on Campylobacter spp Infection Among Children in South Asia.
Author Location Study period Age Study Enrolled Method Diarrhea Positivity Non-diarrhea Positivity
(yrs) setting children stool rate (%) stool rate n (%)

Hasan et al., [48] Mirzapur, 1993–1996 0 to 2 Rural 252 Culture 1748 109 (6.2%) 5679 378 (6.7%)
Bangladesh community
Mondal et al.,a [49] Mirpur, 2008–2009 0 to 1 Urban 147 Culture 420 8 (1.9%) – –
Bangladesh community
b
MAL-ED Diarrhea Non-diarrhea AF (EIA) AI/100 child
stool stool yrs (TAC)c
Platts-Mills et al., Dhaka, 2009–2014 0 to 2 Urban 265 EIA/TAC 1526/1374 2910/3787 0 14.2 (CI 3.8–29.8)
[3,15] Bangladesh community
Vellore, Peri-urban 251 698/623 3181/2767 0 11.1 (CI 5.1–17.2)
India community
Bhaktapur, Peri-urban 240 925/899 3071/4457 1-1 yrs - 0; 8.2 (CI 2.1–15.7)
Nepal community 0–2 yrs -8.8%
N. Feroze, Rural 277 1836/1789 2777/4518 0 14.1 (CI 1.3–31.1)
Pakistan community

EIA – Enzyme immunoassay, TAC – TaqMan Array Card, AF – Adjusted attributable fraction of diarrhea for Campylobacter spp.
AI – Attributable incidence of diarrhea for Campylobacter spp./100 child years.
a
Data on non-diarrheal surveillance stool samples and positivity for Campylobacter jejuni not reported.
b
MAL-ED primary analysis with EIA measured AF testing both diarrheal and non-diarrheal stool.
c
MAL-ED re-analysis with TAC measured AI 100 child-years.

isolation of C. jejuni from diarrheal samples compared to non-diarrheal
samples (7.5 vs. 11.7% in 6–11 months, 5.2 vs 6.9% for 12–17
months). In Mirpur, Mondal et al, isolated C. jejuni by culture in 1.9% of
stool samples in children with diarrhea followed up for a year [49].
4. Discussion
This systematic review showed that reported Campylobacter spp.
detection rates varied widely across the region in South Asia ranging
from 0.3% to 31.8%. Studies on Campylobacter in India, Bangladesh and a
few from Pakistan and Nepal were available but a gap in data from
countries like Afghanistan, Bhutan, Maldives, and Sri Lanka was seen.
The pooled estimate (weighted average proportion) of Campylobacter
spp. among children in South Asia in the random effects model meta-
analysis was 6.96% (95% CI 5.38–8.72%) but showed a high degree of
heterogeneity. Heterogeneity was seen in sample size, definition of
diarrhea applied, diagnostic methodology, study design and duration and
how the proportions were reported rendering the pooled estimate
generated highly variable. A limitation of the pooled estimate based
mostly on cross-sectional studies is potential underestimation due to lack
of testing and reports with culture or EIA from smaller private centers
and government-run primary and secondary health centers, where a
majority of the population accesses health care. However, estimates from
GEMS and MAL-ED studies with community-based recruitment have
addressed this gap to an extent.
While most studies detected Campylobacter by stool culture, there was
considerable variability in culture media and methods used. In a cross-
sectional study conducted among children at a hospital in New Delhi,
diagnostic methods like culture, ELISA and PCR were compared and
culture was found to have a low sensitivity of 37.2% compared to PCR
which was 96.7% [24]. In this study, Ghosh et al. used diagnostic criteria
in which a sample was considered to be positive if both ELISA and PCR
were positive or culture was positive, with 20.8% positivity using this
criterion but dropping to 7.6% culture was taken alone. Rajendran et al.
used only PCR to diagnose Campylobacter related diarrhea, and the pos-
itivity for Campylobacter spp. was 4.6% [28]. Only two studies, one in

5
M. Murugesan et al.
India and another in Pakistan determined the species of Campylobacter
[28,38]. In both these studies, Campylobacter jejuni accounted for more
than 80% of human infection followed by C. coli [38]. In this review, due
to the limited data on antimicrobial susceptibility, with variation in
methods used in the studies included, these data were not analyzed.
In the multi-site GEMS case control study, children under the age of
5 years with moderate to severe diarrhea were enrolled from sentinel
hospitals in 7 sites including India, Pakistan and Bangladesh [45]. Age,
gender, and community matched controls were then identified from the
same demographic surveillance system and enrolled within 14 days of
the case. Pathogen specific attributable fractions (AF) were determined
both for culture-based detection methods and later using C. jejuni/C.
coli primers in PCR based TAC assays. In Bangladesh and Pakistan,
culture-based detection showed that infants had an AF of 1.1 (0.1–2.2)
and 1.7 (0.0–3.3) respectively. In India, children older than 24 months
had an AF of 2.4 (0.0–5.0) [45]. Re-analysis of samples using TAC assay
showed an increased burden of Campylobacter in children in all age
groups in the study. In children under 24 months, the relative ranking
of C. jejuni/C. coli among the causes of diarrhea increased from 7th to
4th (children under 11 months) and from more than 10th to 8th rank
(children aged 12–24 months) but decreased from 3rd to 5th in children
older than 24 months [2]. The GEMS data was used to construct a model
which was fitted to characterize association between pathogen load and
diarrhea, and the attributable incidence (AI) of diarrhea for each
pathogen was calculated. C. jejuni/coli was associated with the highest
attributable incidence of all pathogens tested (187.4 attributable epi-
sodes, 95% CI 115.7–238.3). More recent metagenomic studies have
revealed that non-C. jejuni/C. coli species are also prevalent in these
children and that abundance in the fecal microbiome corelated with
breast feeding [50].
Cohort studies can reflect the true burden of infection, identify risk
factors, and help determine the natural history and sequelae of infections
but are resource intensive to conduct. Over the past decade, three lon-
gitudinal studies were conducted in South Asia. In a multi-site cohort
study (MAL-ED), when samples were tested by EIA, a Campylobacter spp.
attributable fraction for diarrhea in children aged 12–24 months was
seen only in Bhaktapur, Nepal (8.8, 2.0–13.8) [45]. When these samples
were re-analyzed with the TAC assay, Campylobacter jejuni/coli had
significantly higher attributable incidence (>8) in all three south Asian
sites [15]. Future longitudinal cohort studies focusing on Campylobacter
infections using genomic assays are needed to have a better under-
standing of attributable risk and transmission routes in this region. With
increasing antimicrobial usage and resistance, both in human pop-
ulations and the poultry sector, studies with a One Health approach to
generate sustainable prevention strategies, including vaccines, would be
key to decreasing the burden of infection, especially in developing
countries (https://www.onehealthpoultry.org/).
5. Conclusions
In conclusion, Campylobacter spp. are one of the most common agents
causing diarrhea among children in South Asia with a pooled estimate of
7% in the random effects model meta-analysis, but a paucity of data
indicated extensive research needed using genomic and epidemiological
approaches to design effective preventive strategies.
Declaration of competing interest
None.
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