Risk factors for death among children 0–59 months of age with moderate-to-severe diarrhea in Manhiça district, southern Mozambique

Abstract

Background Despite major improvements in child survival rates, the number of deaths due to diarrhea remains unacceptably high. We aimed to describe diarrhea-associated mortality and evaluate risk factors for death among Mozambican children with moderate-to-severe diarrhea (MSD). Methods Between December 2007 and November 2012, children under-five with MSD were enrolled in Manhiça district, as part of the Global Enteric Multicenter study (GEMS). Clinical, epidemiological, and socio-demographic characteristics were collected. Anthropometric measurements were performed and stool samples collected upon recruitment. A follow-up visit ~ 60 days post-enrolment was conducted and verbal autopsies performed in all death cases. Results Of the 916 MSD-cases analyzed; 90% (821/916) completed 60 days follow-up and 69 patients died. The case fatality rate at follow-up was 8% (69/821), and the mortality rate 10.2 (95%CI: 7.75–13.59) deaths per 1000 persons-week at risk. Nearly half of the deaths 48% (33/69) among study participants clustered within 2 weeks of the onset of diarrhea. Typical enteropathogenic Escherichia coli (typical EPEC) and Cryptosporidium were the two pathogens associated to an increased risk of death in the univariate analysis with (HR = 4.16, p = 0.0461) and (H = 2.84, p = 0.0001) respectively. Conversely, Rotavirus infection was associated to a decreased risk of death (HR = 0.52, p = 0.0198) . According to the multivariate analysis, risk factors for death included co-morbidities such as malnutrition (HR = 4.13, p < 0.0001), pneumonia/lower respiratory infection (HR = 3.51, p < 0.0001) or invasive bacterial disease (IBD) (HR = 6.80, p = 0.0009), presenting on arrival with lethargy or overt unconsciousness (HR = 1.73, p = 0.0302) or wrinkled skin (HR = 1.71, p = 0.0393), and cryptosporidium infection (HR = 2.14, p = 0.0038). When restricting the analysis to those with available HIV results ( n = 191, 22% of the total study sample), HIV was shown to be a significant risk factor for death (HR = 5.05, p = 0.0009). Verbal autopsies were conducted in 100% of study deaths, and highlighted diarrhea as the main underlying cause of death 39%, (27/69); followed by HIV/AIDS related deaths 29.0% (20/69) and sepsis 11.6% (8/69). Conclusion Preventive strategies targeting Cryptosporidium, malnutrition and early identification and treatment of associated co-morbidities could contribute to the prevention of the majority of diarrhea associated deaths in Mozambican children. Electronic supplement...

Molecular Diversity of Giardia duodenalis, Cryptosporidium spp., and Blastocystis sp. in Symptomatic and Asymptomatic Schoolchildren in Zambézia Province (Mozambique)

“…In Mozambique, G. duodenalis has been described at infection rates of 1-6% by conventional microscopy in paediatric and clinical populations in Maputo province [31][32][33], and of 8-37% by PCR in patients with HIV and/or tuberculosis in Gaza province and people living in a high endemic area of Sofala province [21,25]. Using enzyme-linked immunosorbent assay (ELISA), G. duodenalis was identified in 10-50% of children with clinical manifestations in different provinces of the country [34][35][36]. The G. duodenalis crude prevalence rate found here (42%) is in the upper range limit of those reported in the aforementioned surveys.…”

Feeding Practices and Associated Factors During Diarrheal Disease Among Children Aged Less Than Five Years: Evidence from the Ethiopian Demographic and Health Survey 2016

“… 20 , 21 Moreover, poor socioeconomic status, large family size, previous experience of child illness and death; poor educational status of caregivers, low maternal and child health services utilization; low coverage, and poor quality of primary health care services were the foremost commonly mentioned factors affecting child feeding practices during and after diarrheal disease. 22 , 23 A study done in that of rural pastoralist communities of the Afar region, Ethiopia showed, only 5.2% of children with diarrhea were offered foods more than usual. 23 In spite of multiple site-specific studies, national-level studies would also have a paramount contribution to the achievement of the national target regarding child health, however, child feeding practices and associated factors during diarrheal disease is remained unstudied in Ethiopia.…”

Rotavirus A infection in children under five years old with a double health problem: undernutrition and diarrhoea – a cross-sectional study in four provinces of Mozambique

“…Studies conducted in Manhiça district, southern Mozambique, showed an association between diarrhoea and undernutrition [ 13 , 14 ]. During 10 years of surveillance, 47% of the hospitalized children presented one or more types of undernutrition, of which 6% were severely undernourished [ 13 ].…”

“…During 10 years of surveillance, 47% of the hospitalized children presented one or more types of undernutrition, of which 6% were severely undernourished [ 13 ]. Also in the same area, another study reported undernutrition as one of the risk factors for mortality in children with moderate-severe-diarrhoea [ 14 ]. To date, most studies of diarrhoeal diseases took place in southern Mozambique, with few studies conducted exclusively in northern provinces [ 15 ].…”