Journal 1 Journal 2 Journal 3 Journal 4 Journal 5

Title Risk Factors for Diarrhea in Risk Factors for Death among Prevalence of diarrhoea and risk Risk factors of Global Causes of Diarrheal
Children under Five Years of Children Less than 5 Years factors among children under five diarrheal disease Disease Mortality in
Age Residing in Peri-urban Old Hospitalized with years old in Mbour, Senegal: a among children in Children ,5 Years of Age: A
Communities in Diarrhea in Rural Western cross-sectional study the East African Systematic Review
Cochabamba, Bolivia Kenya, 2005–2007: A Cohort countries of
Study Burundi, Rwanda
and Tanzania

Introductions Globally, nearly 1 million
deaths annually in children
< 5 years of age are
attributed to diarrhea.1 In
Bolivia, diarrhea is the third
leading cause of morbidity
and mortality in chil- dren
< 5 years of age.1 Diarrhea
surveillance from national
surveys for the country
indicate an alarming rise in
the diar- rhea prevalence
for this age group over time
from 19.2% in 1998 to
Diarrhea is a major cause of Diarrhoeal diseases Diarrheal diseases Despite global
morbidity and mortality among remain an important cause of are a major public success in the reduction
children ,5 y old in sub-Saharan mortality and morbidity health burden, of all cause and
Africa. Of the estimated 4,2 among children, particularly killing 1.8 million diarrhea- specific
million deaths in children ,5 y old in low- and middle-income people annually and mortality in the past 30
in Africa in 2008, diarrhea caused countries. In Senegal, disproportionately years, diarrhea remains
the largest proportion (19%); diarrhoea is responsible for affecting children in the second leading
followed by pneumonia (18%), 15% of all deaths in children developing cause of death due to
and malaria (16%). under the age of five and is countries. Globally, infections among
the third leading cause of diarrhea is the children under five
childhood deaths. For targeted second leading years of age
planning and implementation cause of death of worldwide. It is
of prevention strategies, a children under five, estimated that diarrhea
context-specific with approximately accounted for 9?9% of
31.3% in 2008. In understanding of the 760,000 of these the 6?9 million deaths
Cochabamba, Bolivia, the determinants of diarrhoeal children dying among children under 5
site of this study, the most diseases is needed. The aim of annually. In in 2011. Several
recent government survey this study was to identify risk sub-Saharan Africa, organisms have been
from 2008 reported a factors of diarrhoeal diseases diarrhea is the implicated as important
diarrhea prevalence of in children under the age of primary cause of causes of these deaths,
36.2% for children < 5 five in Mbour, Senegal. childhood yet there has not been a
years of age for the morbidity and review using
department. mortality. Most standardized methods
diarrheal cases can to determine the
be prevented using importance of all of the
safe drinking water, common pathogens.
basic hygiene and The Child Health
sanitation measures. Epidemiology
Diarrheal diseases Reference Group
are more prevalent (CHERG) has
in estimated the causes of
child deaths from
the rainy season4 major causes since
and associated with 2001. We have
socioeconomic undertaken this review
status, especially to develop estimates of
with mother’s pathogen-specific
educational status. diarrhea mortality
 The objective of among children under 5
this project was to years of age. We
determine factors present the results of a
that predicted systematic literature
diarrheal disease in review of studies of
children under five diarrhea etiology in
in Burundi, hospitalized children
Rwanda, and and use these results to
Tanzania in 2010 estimate the global
using the burden of diarrhea
Demographic and mortality by pathogen
Health Survey for children under 5
(DHS) Program years of age for 2011.
data on child health.

Methods Study population. This Laboratory Methods Between February and Data were obtained To use this method
prospective cohort study March 2014, a cross-sectional from the DHS we required at least 3
was con- ducted in eight Whole stool specimens and/or survey was conducted in four program (2010) on studies, where each
peri-urban zones southeast rectal swabs placed in Cary-Blair zones of Mbour to estimate child health for study reported both 0–
and adjacent to the city of transport medium were cultured the burden of diarrhoeal Burundi (N=7198), 59 months and age
Cochabamba, located in for Salmonella, Shigella, Campylo- diseases (i.e. diarrhoea Rwanda (N=8418), group X. In situations
the Cochabamba bacter, and Vibrio species by episodes in the 2 weeks and Tanzania (N= where less than 3
Department of Bolivia. standard techniques, and tested preceding the survey) and 7295). IBM SPSS studies were available
Zones were selected that for rotavirus by enzyme-linked associated risk factors. The Statistics Version we employed an
lacked access to munici- pal immunoassay (EIA) (catalogue zones covered urban central, 22 (IBM Corp., alternative method
water and sanitation number 696004, Meridian peri-central, north peripheral Armonk, NY) where the conversion
through a piped network. Biosciences, Inc.) at the and south peripheral areas. software was used factor for age group X
This study was conducted KEMRI/CDC laboratory in Kisumu, Overall, 596 households were to complete all was taken as the ratio
in collaboration with Kenya. Campylobacter isolates surveyed by a questionnaire, analyses. of the median prev0–59
Fundacio ́n contra el were tested for hippurate yielding information on Descriptive to median prevX
Hambre–Bolivia (Food for hydrolysis to identify C. jejuni sociodemographic, statistics were (median (prev0–
the Hungry). (hippurate positive) from C. coli environmental and hygiene completed for all 59)/median (prevX)).
(hippurate negative and grew on behavioural factors. variables. Simple For this approach we
Campylobacter selective media at Univariable and multivariable and multiple required that 3 or more
42uC) or Campylobacter species. logistic regression analyses logistic regressions studies contribute to
Vibrio cholerae isolates were were used to identify risk were completed to each of the two
assessed for the O1 serogroup factors associated with the determine factors medians, but dropped
using commercial antisera occurrence of diarrhoea. that predicted the Method 1
(catalogue number LL-13916, Lee diarrheal disease in requirement that
Labs, Becton-Dickinson). the previous two individual studies
Antimicrobial susceptibilities of weeks. All variables report both age groups.
Salmonella, Shigella, and Vibrio were controlled for If neither of these sets
isolates to a panel of in the final model. of conditions were met,
antimicrobial agents (VWR Odds ratios and we borrowed the
International) confidence intervals conversion factor for
(amoxicillin-clavulanic acid; were reported. the age group X from a
ampicillin; ceftriaxone; similar age group
chloramphen- icol; ciprofloxacin; within the same
 gentamicin; kanamycin; nalidixic pathogen (for instance,
acid; strep- tomycin; sulfisoxazole; used the conversion
tetracycline; factor calculated for
trimethoprim-sulfamethoxa- zole) studies including
was determined by the disk infants 0–11 months of
diffusion method at the KEMRI/ age for studies that
CDC laboratory in Kisumu, Kenya. included infants 0–5
Isolates with moderate or months of age) or from
intermediate susceptibility were a similar pathogen
classified as susceptible. (conversion factor for
Laboratory results were age group X for a study
communicated to each hospital. on EPEC borrowed
from studies on ETEC).
The 0–59 months
prevalence proportion
for each pathogen was
estimated using the
median individual
study 0–59 months
pathogen prevalence.

Results A total of 952 children were From May 23, 2005 to May The reported prevalence of From 22 643 citations
followed prospectively for 5 22, 2007, 1,146 children ,5 y diarrhoea among children identified in the
months, 484 children
received a water filter in
their house- hold and 468
children did not receive a
water filter. There were no
large differences observed
between the filter and
non-filter groups on any of
the demographic variables
mea- sured. The median
age of these children was
20 months for both the
filter and non-filter groups
with the range being
between 2 and 40 months.
Forty-eight percent of the
children were female, and
the majority resided in
house- holds with Spanish
being their primary
language.
old hospitalized with diarrhea
were enrolled; 508 (44%)
were female. The
participation rate was 90%;
among those who declined,
the reasons were the caretaker
was in a hurry (87%), refused
(8%), or was unavailable
(5%). No caretakers with
severely ill children refused
participation. Of 1,146
enrolled children (757 and
389 at Siaya District Hospital
and Bondo District Hospital,
respectively), 107 died during
hospitalization, for an
in-hospital case fatality ratio
(CFR) of 9?3% (9?4% and
9?3% at Siaya District
Hospital and Bondo District
Hospital, respectively). The
sex-specific CFR among
children with diarrhea who
died during hospitalization
under the age of five during
the 2 weeks preceding the
survey was 26%. Without
adjustment, the highest
diarrhoea prevalence rates
were observed in the
peri-central (44.8%) and
urban central zones (36.3%).
Multivariable regression
revealed significant
associations between
diarrhoeal diseases and
unemployment of mothers
(adjusted odds ratio [aOR] =
1.62, 95% confidence interval
[CI]: 1.18–2.23), use of open
bags for storing household
waste (aOR = 1.75, 95% CI:
1.00–3.02), evacuation of
household waste in public
streets (aOR = 2.07, 95% CI:
1.20–3.55), no treatment of
stored drinking water (aOR =
1.69, 95% CI: 1.11–2.56) and
electronic search, 1 003
articles were selected
for further evaluation
(Fig. 1); 840 articles
were excluded because
they had one or more
of the exclusion criteria
(About 35% because
they were not
longitudinal studies or
inappropriate
laboratory methods
were used, 31%
because no data was
given for children ,5
years of age, 23% for
studies that lasted less
than 12 months of
duration, and the rest
because data were
reported after rotavirus
vaccine introduction,
duplicate publications
or reporting results on a
was 10?2% for females (52 of use of shared toilets (aOR = pathogen not included
508) and 8?6% for males (55 1.69, 95% CI: 1.11–2.56). in our list).
of 638), p = 0?4. The median
age at presentation was 9 mo
old for children who died and
those who survived. Eight
enrolled children were
neonates, of whom none died.