Determinants of severe dehydration from diarrheal disease at hospital presentation: Evidence from 22 years of admissions in Bangladesh

Abstract

Background: To take advantage of emerging opportunities to reduce morbidity and mortality from diarrheal disease, we need to better understand the determinants of life-threatening severe dehydration (SD) in resource-poor settings.

Methodology/findings: We analyzed records of patients admitted with acute diarrheal disease over twenty-two years at the International Centre for Diarrhoeal Disease Research, Bangladesh (1993-2014). Patients presenting with and without SD were compared by multivariable logistic regression models, which included socio-demographic factors and pathogens isolated. Generalized additive models evaluated non-linearities between age or household income and SD. Among 55,956 admitted patients, 13,457 (24%) presented with SD. Vibrio cholerae was the most common pathogen isolated (12,405 patients; 22%), and had the strongest association with SD (AOR 4.77; 95% CI: 4.41-5.51); detection of multiple pathogens did not exacerbate SD risk. The highest proportion of severely dehydrated patients presented in a narrow window only 4-12 hours after symptom onset. Risk of presenting with SD increased sharply from zero to ten years of age and remained high throughout adolescence and adulthood. Adult women had a 38% increased odds (AOR 1.38; 95% CI: 1.30-1.46) of SD compared to adult men. The probability of SD increased sharply at low incomes. These findings were consistent across pathogens.

Conclusions/significance: There remain underappreciated populations vulnerable to life-threatening diarrheal disease that include adult women and the very poor. In addition to efforts that address diarrheal disease in young children, there is a need to develop interventions for these other high-risk populations that are accessible within 4 hours of symptom onset.

Fig 1

(A) Monthly frequency of pathogens isolated from 1993–2014. Red = V. cholerae; yellow = rotavirus; green = ETEC; blue = Aeromonas spp.; Shigella spp. = purple; Campylobacter spp. = orange. Non-typhoidal Salmonella = black. Surveillance enrollment rates were 4% for 1993–1995 and 2% for 1996–2014. (B) Proportion of patients presenting with severe (red), some (yellow), and no (green) dehydration across the study period.

Fig 2. Distribution of high-priority pathogens identified as a function of patient age.

Fig 3

Predicted probability of severe dehydration as a function of age, for all patients (A) or patients with specific pathogens (B-H). Panel A shows sex-stratified age-specific risks for all patients (male = blue, female = red). Shading represents the 95% confidence interval.

Fig 4. Predicted probability of severe dehydration as a function of family income Z score, by pathogen.

Panel A shows sex-stratified risks as a function of income Z score for all patients (male = blue, female = red). Shading represents the 95% confidence interval. Remaining panels (B-H) show risk as a function of income Z score for specific pathogens.

Fig 5. Dehydration status as a function of symptom duration prior to presentation.

The proportion of patients with severe (red), some (yellow), and no (green) dehydration are shown for all patients (A) or patients with a specific pathogen (B-H).