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Multicenter Study
. 2019 Apr 15;19(1):322.
doi: 10.1186/s12879-019-3948-9.

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

Sozinho Acácio  1   2 , Inácio Mandomando  1   2 , Tacilta Nhampossa  1   2 , Llorenç Quintó  3 , Delfino Vubil  1 , Charfudin Sacoor  1 , Karen Kotloff  4 , Tamer Farag  4 , Dilruba Nasrin  4 , Eusébio Macete  1   2 , Myron M Levine  4 , Pedro Alonso  1   3 , Quique Bassat  5   6   7   8
Affiliations
Multicenter Study

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

Sozinho Acácio et al. BMC Infect Dis. .

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.

Keywords: Children; Death; Moderate-to-severe diarrhea; Mozambique; Risk factor.

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Conflict of interest statement

Ethics approval and consent to participate

The study, conducted under the framework of the GEMS project, took place in seven LMICs and was coordinated by the Center for Vaccine Development (Baltimore, Maryland, USA) in collaboration with the Barcelona institute of Global Health (ISGlobal), in Spain. The GEMS protocol and informed consent were both approved by the National Bioethics Committee for Health of Mozambique (CNBS – IRB00002657), the ethics committee of the Hospital Clínic of Barcelona, and The Institutional Review Board at the University of Maryland. After informing the objectives and characteristics of the study a written informed consent was obtained from the child’s primary caretaker, and a witnessed consent was obtained for illiterate parents/caretakers.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no Competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Hospital visits due to moderate-to-severe diarrhea among children aged 0–59 months of age within DSS area in Manhiça, Mozambique, December 2007 – November 2012
Fig. 2
Fig. 2
Proportion of children who sought health care within 7 days of onset of episode
Fig. 3
Fig. 3
Mortality at 60 days follow-up among children 0–59 months of age with diarrhea with estimated median time to death for each age group
See this image and copyright information in PMC

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