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Association between domestic animal exposure and diarrhea prevalence in under- five children in low- and middle-income countries: a systematic review and meta-analysis

BMC Pediatrics volume 24, Article number: 601 (2024) Cite this article

Abstract

Background

Diarrheal disease is still the leading cause of morbidity and mortality in children, despite significant progress in diarrhea interventions. Zoonotic transmission is the main cause of the emergence and re-emergence of diseases. Domestic animals are often close to humans, particularly in resource-poor countries. Despite evidence of environmental contamination, there have been limited studies conducted to examine the association between domestic animal exposure and diarrheal disease in low- and middle-income countries (LMIC). Therefore, this systematic review and meta-analysis examines the association between domestic animal exposure and diarrheal disease in children under five years of age in LMIC.

Methods

The search strategy followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for the reporting of systematic reviews. All appropriate databases were searched to find relevant articles. Research studies were selected for review if they reported an outcome variable that measured diarrhea and exposure variables of any domestic animals. A data extraction form was used to extract information from each study. The quality of the individual articles was assessed using the Joanna Briggs Institute (JBI’s) critical appraisal tools. Publication bias was checked using a funnel plot, Egger’s regression test, and Begg’s test. The heterogeneity of studies was checked using the Galbraith plot and the I-squared test. A sensitivity analysis was conducted, and a meta-analysis was conducted using STATA 17.

Results

After reviewing 113 articles, 11 articles fulfilled the inclusion criteria hence considered for meta-analysis. The finding of these 11 studies revealed that study participants who had animal exposure had 1.95 higher odds of diarrhea as compared to participants who hadn’t animal exposure (OR: 1.95, 95%CI: 1.25, 2.66).

Conclusions and recommendations

This study reported that diarrheal disease was associated with study subjects who had domestic animal exposure. Therefore, more comprehensive research is needed on specific behaviors and interventions surrounding animal husbandry that may affect the transmission of pathogens between animals and humans; this would facilitate the design and implementation of measures to reduce animal exposure in the domestic environment.

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Introduction

The passage of three or more loose or watery stools in 24-hour period, or an increase in stool frequency or liquidity that is deemed abnormal, is referred to as diarrhea [1]. Childhood diarrheal disease continues to be a major source of death and morbidity even with the notable drop in under-five mortality [2]. Diarrhea is the second greatest cause of death for children in society, accounting for 15% of all fatalities in children under five worldwide [3]. The majority of under-five deaths occurred in developing countries or economically deprived areas; almost four-fifths of these deaths occurred in Sub-Saharan Africa (SSA) and South Asia [4]. Young children in low- and middle-income countries (LMICs) often have three episodes of diarrhea per year, which can lead to malnourishment, stunted growth, and negative cognitive consequences [5]. Under-five diarrhea is still more common and presents a serious, persistent public health issue in Sub-Saharan Africa [6].

The recent rise and resurgence of new diseases is largely attributed to the transmission of infectious diseases from animals to humans [7]. A zoonotic disease is an illness or infection that can naturally spread from humans to other vertebrates or from animals to humans. The source of more than 60% of human infections is zoonotic. This encompasses an extensive range of pathogens, including bacteria, viruses, fungi, protozoa, and parasites [8]. Humans contract diarrheal diseases when feces contaminate water or food sources, transferring enteric bacteria, parasites, or viruses to humans. Human diarrhea is primarily caused by environmental contamination from human feces, although zoonotic sources can also contribute to transmitting diarrheal disease pathogens [9, 10]. Human diarrhea may result from the introduction of novel zoonotic infections or from an increase in the transmission of pathogens that are common to both people and animals. Certain animal hosts act as reservoirs for infections that cause diarrheal diseases. For example, human infections with Salmonella and Campylobacter are primarily linked to poultry, but human infections with enterohemorrhagic Escherichia coli (EHEC) are primarily linked to ruminants [11].

All across the world, domestic animals and poultry are frequently found near people, but they are especially noticeable in poor countries where animal husbandry is the main source of income. Households commonly keep livestock and poultry close to human living areas due to environmental, cultural, and economic factors. This allows the animals to move freely and sleep inside the human house [12]. However, this practice increases the likelihood of animal fecal contamination within the household, which could lead to the transmission of zoonotic pathogens carried by these domestic animals [13]. These pathogens are a cause of diarrheal diseases in humans and have not received much attention despite evidence of their environmental contamination [13]. Furthermore, there are limited up-to-date studies on the association between domestic animal exposure and diarrheal disease specifically in low and middle income countries. So, this systematic review and meta-analysis aimed to explore the association between exposure to domestic animals and diarrheal disease among under-five children of low- and middle-income countries. The findings from this systematic review will highlight the association between exposure to domestic animal feces and childhood diarrhea with implications to improve interventions and accelerate the reduction of childhood diarrhea in low and middle-income countries.

Methods

Search strategy and selection criteria

The search strategy followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for the reporting of systematic reviews [14], and was registered with PROSPERO (registration number: CRD42023450438). A search for articles published in English was conducted using PubMed/MEDLINE, Hinari, CINAHL, Web of Science, Science Direct, Cochrane Library, and grey literature (Google Scholar). The Boolean operators “OR” and “AND” were used to search for relevant articles using Medical Subject Headings (MeSH) and keyword terms and phrases, both separately and in combination. To obtain possibly pertinent studies, the authors employed the technique of “snowballing” the references of publications they have identified. The keywords and phrases “under-five children”, Younger than five years, diarrhea, diarrhoea, diarrheal disease, associated factors, animal, domestic animal, poultry, chickens, livestock, and cattle were used in separation or in combination to retrieve relevant articles on association between domestic animal exposure and diarrhea prevalence in low- and middle-income countries. The search of the literature was conducted between June 1, 2023 to July 1, 2023. All papers published between the 1st of July, 2000, and to 1st of July, 2023 were considered.

After the verification of the eligibility requirements, abstracts were independently screened, and full-text papers were searched. All review papers’ and original publications’ reference lists were examined for any relevant studies.

Inclusion criteria

Study area

Only studies conducted in low and middle-income countries.

The low- and middle-income group classifications are based on the World Bank 2022 classification. Accordingly, the low- income countries are $1,085 or less; lower middle-income countries, $1,086 to $4,255; upper middle income, $4,256 to $13,205 gross national income (GNI) per capita.

Population

Only studies involving under-five year children.

Publication condition

Published articles were included.

Study design

All observational study designs (i.e., cross-sectional, case-control and cohort). reporting the prevalence of diarrhea in under-five children and exposure variables of any of domestic animal were eligible for this review.

Exposure to domestic animals refers to the extent to which a person or population comes into contact with domestic animals that are typically used for agricultural purposes, such as swine, cattle, goat, sheep, or poultry.

Language

Only articles reported in the English language were considered.

Exclusion criteria

  • Citations without abstract and/ or full-text, anonymous reports, and editorials were excluded from the analysis.

Data extraction

A data extraction form was used to extract information from each study. For each included article, the first author’s last name, year of publication, study setting, study design, study period, sample size, study population, research objectives, results, and conclusions were recorded.

Quality assessment

For studies that were included, the quality of the individual articles and body evidence was assessed using the Joanna Briggs Institute (JBI’s) critical appraisal tools [15]. All studies were graded concerning their quality and summary data regarding data extraction fields was compiled. Studies were considered low risk when they scored 50% and above on the quality assessment indicators.

Statistical analysis

Publication bias was checked by funnel plot and more objectively through Egger’s regression test [16] and Begg’s test [17]. The heterogeneity of studies was quantified using the I-squared statistic [18]. Pooled analysis was conducted using a weighted inverse variance random-effects model [19]. Subgroup analysis was done using the study class and design. Sensitivity analysis was employed to see the effect of a single study on the overall estimation. STATA version 17 statistical software was used for meta-analysis. The eligible studies were synthesized to describe the association between domestic animal exposure and diarrhea prevalence in low and middle-income countries.

Results

Description of publications

The search terms were retrieved from PubMed (n = 265), Hinari (n = 11), Science Direct (n = 23), Cochrane Library (n = 21), and Google Scholar (n = 12). After duplication was removed, the search terms returned a total of 113 articles for screening as reflected in the flow diagram (Fig. 1), through which a total of 11 articles were identified for full-text review.

Fig. 1
figure 1

Flow diagram of literature search, review and selection according to PRISMA

Full size image

Study characteristics

Of the 11 included studies, six were from the middle-income group and the rest five were from the low-income group. Regarding the study design six were cross-sectional, three studies were cohort and the rest two studies were case-control (Table 1).

Table 1 Studies included in the systematic review and meta-analysis of the association between domestic animal exposure and diarrheal disease among under-five children in LMIC
Full size table

Quality of studies

The JBI quality appraisal criteria established for cross-sectional, case-control, and cohort studies were used. The studies included in this systematic review and meta-analysis had no considerable risk. Therefore, all the studies were considered (Table 1).

Publication bias

A funnel plot was done to check the presence of publication bias (Fig. 2). The result of the funnel plot showed that there was asymmetrical distribution of articles. To confirm this asymmetry, we conducted objective (Egger’s and Begg’s tests) based tests. The results of Egger’s (p = 0.61) and Begg’s tests (p = 1.00) showed that there was no statistically significant publication bias in estimating the association between domestic animal exposure and diarrheal disease.

Fig. 2
figure 2

Funnel plot with Pseudo 95% confidence limits of the pooled estimate for the association between domestic animal exposure and diarrheal disease in LMIC

Full size image

Association between domestic animal exposure and diarrheal disease

In this review, we examined the association between human domestic animal exposure and diarrheal disease. From the total eleven studies included, eight studies indicated that domestic animal exposure was significantly associated with diarrheal disease [20,21,22,23,24,25,26,27]. Regarding the analysis method, regression analysis [20, 22,23,24,25,26,27,28,29] and chi-square (χ2) test [21, 30] were done. These studies also reported that study subjects who had domestic animal exposure were more likely to have diarrheal disease. Three studies reported that domestic animal exposure was not significantly associated with diarrheal disease [28,29,30]. The pooled result of this meta-analysis revealed that study participants who had animal exposure had 1.95 higher odds of having diarrhea as compared to participants who hadn’t animal exposure (OR: 1.95, 95% CI: 1.25, 2.66) (Fig. 3).

Fig. 3
figure 3

The pooled odds ratio of the association between domestic animal exposure and diarrheal disease among under-five children in low- and middle-income countries (LMIC)

Full size image

Heterogeneity test

The test of heterogeneity was checked by the Galbraith plot and the entire points within the 95% confidence bound (Fig. 4). However, the statistical (objective) test indicates that the included studies were characterized by considerable heterogeneity (I2 = 100.0%; p < 0.001); hence, a random effect meta-analysis model was employed to estimate the final analysis.

Fig. 4
figure 4

Galbraith plot on the association between domestic animal exposure and diarrheal disease

Full size image

Subgroup analysis

Since there is considerable heterogeneity among studies, the subgroup analysis based on the income group and study design was done. Based on the income group, the heterogeneity is slightly decreased in the lower income group. However, in middle-income countries, the heterogeneity does not decrease (Fig. 5).

Fig. 5
figure 5

Forest plot of subgroup analysis by income group for the association between domestic animal exposure and diarrheal disease in LMIC

Full size image

The subgroup analysis based on study design indicates that the heterogeneity of the studies was slightly decreased. In the case-control study design and cohort study design the heterogeneity is slightly decreased (Fig. 6).

Fig. 6
figure 6

Forest plot of subgroup analysis by study design for the association between domestic animal exposure and diarrheal disease in LMIC

Full size image

Sensitivity analysis

The sensitivity analysis was done. All the studies had shown no impact on the overall estimation of effect size (Fig. 7).

Fig. 7
figure 7

Sensitivity analysis showed the pooled odds ratio when the studies omitted step-by-step

Full size image

Discussion

This review shows that diarrheal disease transmission by zoonotic agents that occur in the domestic setting was common. Evidence suggests that there is an association between exposure to domestic animals and diarrheal disease in under-five children in LMIC. This result is in agreement with other research done on diarrhea prevalence risk factors [31,32,33]. This is because children and adults in LMIC can be exposed to animal feces, leading to infections with bacteria, helminth, and/or protozoan [34,35,36,37,38,39].

Domestic animals are a significant source of zoonotic infection and should be considered an important contributor to diarrheal illness. There is observed heterogeneity in the effect size, despite the overall weight of evidence suggesting there is an association between domestic animal exposure and diarrheal disease. This could be explained by variables that vary between the studies, including the study area, study design, sampled population, age of the population, housing and community conditions, hygiene and sanitation practice, nature of the animal exposure, and survey methods.

The limited available data and high heterogeneity of effect size between studies, in combination with the strength of the associations observed across studies in the systematic review, highlight the need for more research on the association between animal exposure and diarrheal disease, especially studies that ascertain the microbial cause of diarrheal disease.

Limitations of the study

This meta-analysis has some limitations. The first limitation of this study was only English language articles or reports were considered to conduct this review. Almost all research included in this meta-analysis used the WHO tool for diarrheal assessment, its occurrence was determined based on the reports of mothers without the confirmation of physicians. Therefore, this result might be affected by social desirability bias.

Conclusions and recommendations

This study reported that diarrheal disease in under-five children was associated with domestic animal exposure. To facilitate the design and implementation of measures to reduce animal exposure in the domestic environment, more comprehensive research is required on specific behaviors and interventions surrounding animal exposure that may affect the transmission of pathogens between animals and humans. More studies should be carried out on domestic animals and human behaviors, the existence and condition of animal corralling structures, and individual approaches to different animal husbandry techniques. Moreover, health education about animal handling practices as well as, proper disposal of wastes including excreta in integration with the existing health extension program is recommended.

Data availability

All data generated or analyzed during this study are included in this published article.

Abbreviations

LMIC:

Low- and middle-income countries

PRISMA:

Preferred reporting items for Systematic Review and Meta-analysis

SSA:

Sub-Saharan Africa

WHO:

World Health Organization

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Acknowledgements

The authors would like to acknowledge Debre Markos University and Bahir Dar University for every support in this systematic review and meta-analysis.

Funding

No external funding was received for this study.

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Authors and Affiliations

  1. Department of Environmental Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia

    Atalay Getachew

  2. School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

    Atalay Getachew, Mesafint Molla, Amha Admasie & Muluken Azage Yenesew

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Contributions

AG designed the systematic review and meta-analysis, developed the search strategy, and drafted the protocol. AG and MM performed a search strategy and conducted data selection and extraction. MM, AA, and MAY improved the drafted systematic review and meta-analysis and provided their expertise in the methodological section. All authors were involved in data analysis and interpretation of the results and write-up of the manuscript. All authors have read and approved the final manuscript.

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Correspondence to Atalay Getachew.

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Getachew, A., Molla, M., Admasie, A. et al. Association between domestic animal exposure and diarrhea prevalence in under- five children in low- and middle-income countries: a systematic review and meta-analysis. BMC Pediatr 24, 601 (2024). https://doi.org/10.1186/s12887-024-05084-4

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BMC Pediatrics

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