Risk factors for predicting diarrheal duration and morbidity in children with acute diarrhea

Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association study

BACKGROUND

Diarrhoea causes many deaths in children younger than 5 years and identification of risk factors for death is considered a global priority. The effectiveness of currently recommended fluid management for dehydration in routine settings has also not been examined.

METHODS

For this observational, association study, we analysed prospective clinical data on admission, immediate treatment, and discharge of children age 1-59 months with diarrhoea and dehydration, which were routinely collected from 13 Kenyan hospitals. We analysed participants with full datasets using multivariable mixed-effects logistic regression to assess risk factors for in-hospital death and effect of correct rehydration on early mortality (within 2 days).

FINDINGS

Between Oct 1, 2013, and Dec 1, 2016, 8562 children with diarrhoea and dehydration were admitted to hospital and eligible for inclusion in this analysis. Overall mortality was 9% (759 of 8562 participants) and case fatality was directly correlated with severity. Most children (7184 [84%] of 8562) with diarrhoea and dehydration had at least one additional diagnosis (comorbidity). Age of 12 months or younger (adjusted odds ratio [AOR] 1·71, 95% CI 1·42-2·06), female sex (1·41, 1·19-1·66), diarrhoea duration of more than 14 days (2·10, 1·42-3·12), abnormal respiratory signs (3·62, 2·95-4·44), abnormal circulatory signs (2·29, 1·89-2·77), pallor (2·15, 1·76-2·62), use of intravenous fluid (proxy for severity; 1·68, 1·41-2·00), and abnormal neurological signs (3·07, 2·54-3·70) were independently associated with in-hospital mortality across hospitals. Signs of dehydration alone were not associated with in-hospital deaths (AOR 1·08, 0·87-1·35). Correct fluid prescription significantly reduced the risk of early mortality (within 2 days) in all subgroups: abnormal respiratory signs (AOR 1·23, 0·68-2·24), abnormal circulatory signs (0·95, 0·53-1·73), pallor (1·70, 0·95-3·02), dehydration signs only (1·50, 0·79-2·88), and abnormal neurological signs (0·86, 0·51-1·48).

INTERPRETATION

Children at risk of in-hospital death are those with complex presentations rather than uncomplicated dehydration, and the prescription of recommended rehydration guidelines reduces risk of death. Strategies to optimise the delivery of recommended guidance should be accompanied by studies on the management of dehydration in children with comorbidities, the vulnerability of young girls, and the delivery of immediate care.

FUNDING

The Wellcome Trust.

Factors Associated with the Duration of Moderate-to-Severe Diarrhea among Children in Rural Western Kenya Enrolled in the Global Enteric Multicenter Study, 2008-2012

Diarrheal disease is a leading cause of death among young children worldwide. As rates of acute diarrhea (AD; 1-6 days duration) have decreased, persistent diarrhea (PD; > 14 days duration) accounts for a greater proportion of the diarrheal disease burden. We describe factors associated with the duration of moderate-to-severe diarrhea in Kenyan children < 5 years old enrolled in the Global Enteric Multicenter Study. We found 587 (58%) children experienced AD, 360 (35%) had prolonged acute diarrhea (ProAD; 7-13 days duration), and 73 (7%) had PD. We constructed a Cox proportional hazards model to identify factors associated with diarrheal duration. Risk factors independently associated with longer diarrheal duration included infection with Cryptosporidium (hazard ratio [HR]: 0.868, P = 0.035), using an unimproved drinking water source (HR: 0.87, P = 0.035), and being stunted at enrollment (HR: 0.026, P < 0.0001). Diarrheal illness of extended duration appears to be multifactorial; given its association with adverse health and development outcomes, effective strategies should be implemented to reduce the duration and severity of diarrheal illness. Effective treatments for Cryptosporidium should be identified, interventions to improve drinking water are imperative, and nutrition should be improved through exclusive breastfeeding in infants ≤ 6 months and appropriate continued feeding practices for ill children.

Global Economic Burden of Norovirus Gastroenteritis

Background

Despite accounting for approximately one fifth of all acute gastroenteritis illnesses, norovirus has received comparatively less attention than other infectious pathogens. With several candidate vaccines under development, characterizing the global economic burden of norovirus could help funders, policy makers, public health officials, and product developers determine how much attention and resources to allocate to advancing these technologies to prevent and control norovirus.

Methods

We developed a computational simulation model to estimate the economic burden of norovirus in every country/area (233 total) stratified by WHO region and globally, from the health system and societal perspectives. We considered direct costs of illness (e.g., clinic visits and hospitalization) and productivity losses.

Results

Globally, norovirus resulted in a total of $4.2 billion (95% UI: $3.2–5.7 billion) in direct health system costs and $60.3 billion (95% UI: $44.4–83.4 billion) in societal costs per year. Disease amongst children <5 years cost society $39.8 billion, compared to $20.4 billion for all other age groups combined. Costs per norovirus illness varied by both region and age and was highest among adults ≥55 years. Productivity losses represented 84–99% of total costs varying by region. While low and middle income countries and high income countries had similar disease incidence (10,148 vs. 9,935 illness per 100,000 persons), high income countries generated 62% of global health system costs. In sensitivity analysis, the probability of hospitalization had the largest impact on health system cost estimates ($2.8 billion globally, assuming no hospitalization costs), while the probability of missing productive days had the largest impact on societal cost estimates ($35.9 billion globally, with a 25% probability of missing productive days).

Conclusions

The total economic burden is greatest in young children but the highest cost per illness is among older age groups in some regions. These large costs overwhelmingly are from productivity losses resulting from acute illness. Low, middle, and high income countries all have a considerable economic burden, suggesting that norovirus gastroenteritis is a truly global economic problem. Our findings can help identify which age group(s) and/or geographic regions may benefit the most from interventions.

Global age distribution of pediatric norovirus cases

Norovirus is increasingly recognized as a major cause of acute gastroenteritis among children <5 years of age. We searched for publications that reported detailed age distributions of pediatric norovirus cases, and assessed associations between age distribution and socio-demographic factors to identify the most critical age periods to prevent norovirus cases among young children. Approximately 70% of pediatric norovirus cases occurred between 6 and 23 months of age. A younger age distribution was found in lower income countries and inpatient settings. These findings suggest that a norovirus immunization schedule completed by 6 months could have the potential to prevent about 85% of pediatric cases, while a vaccine delivered at 12 months of age would only have the potential to prevent about 50% of pediatric cases. With a younger age distribution in lower income settings, early prevention would be even more critical.

Risk factors of diarrhea in children under 5 years in Al-Mukalla, Yemen

Objectives:

To assess the risk factors associated with diarrhea among children below 5-years-old in Mukalla, Yemen, and compare with other studies.

Methods:

We conducted a case-control study on 200 children (100 cases and 100 controls) who attended the Maternity and Child Hospital, outpatient-clinics, and the Primary Health Care Centers in Al-Mukalla, Hadhramout, Yemen between February and April 2013.

Results:

We found that the significant risk factors associated with diarrhea were crowded housing (odds ratio [OR] 2.02; p=0.02; confidence interval [CI] 1.03-4.01), incomplete vaccination of the child (OR=2.02; p=0.027; CI: 1.08-3.8), and recurrent diarrheal illness during the last 3 months (OR=6.61; p=0.001; CI: 3.41-12.90).

Conclusion:

Diarrheal diseases are strongly associated with incomplete vaccination, recurrent diarrheal disease, and crowded housing.

Zinc supplementation in acute diarrhea

OBJECTIVE

To determine the effect of zinc supplementation on the duration of acute diarrhea in children.

METHODS

A search was conducted in PubMed, the Cochrane Library database, China Biology Medicine (CBM), CNKI, VIP, and Wanfang Data to find studies on zinc supplementation for children with acute diarrhea from the date of establishment of the respective databases to June 2013. Clinical trials were included, and reviews or other types of studies were excluded. Considering the inclusion criteria, articles were evaluated by two individual investigators. The Cochrane Handbook 5.0.2 was used to evaluate the methodological quality. RevMan 5.2 software was used for meta-analysis. Heterogeneity of the included studies was tested to select a proper effect model. Measurement data were expressed as standard mean difference (SMD), weighted mean difference (WMD), and 95 % confidence interval (CI).

RESULTS

A total of 860 relevant articles were found, and 8 randomized control trials that met the inclusion criteria were included. Meta-analysis showed a significant difference in the duration of acute diarrhea between treatment and control groups, with a WMD of -14.47 (95 % CI: -25.06 to -3.89; P = 0.007). However, significant heterogeneity was found among the studies. Sensitivity analysis and subgroup analyses based on admission condition, sample size and age group were also performed, for which heterogeneity cannot be completely eliminated.

CONCLUSIONS

Zinc supplementation can decrease the duration of acute diarrhea in children, but future studies should carry out a more thorough analysis in less heterogeneous subjects for a more definitive conclusion.

Measuring coverage in MNCH: current indicators for measuring coverage of diarrhea treatment interventions and opportunities for improvement

Diarrhea morbidity and mortality remain important child health problems in low- and middle-income countries. The treatment of diarrhea and accurate measurement of treatment coverage are critical if child mortality is going to continue to decline. In this review, we examine diarrhea treatment coverage indicators collected in two large-scale community-based household surveys--the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS). Current surveys do not distinguish between children with mild diarrhea episodes and those at risk for dehydration. Additional disease severity questions may improve the identification of cases of severe diarrhea but research is needed to identify indicators with the highest sensitivity and specificity. We also review the current treatment indicators in these surveys and highlight three areas for improvement and research. First, specific questions on fluids other than oral rehydration salts (ORS) should be eliminated to refocus the treatment of dehydration on ORS and to prevent confusion between prevention and treatment of dehydration. Second, consistency across surveys and throughout translations is needed for questions about the caregiver behavior of "offering" the sick child fluid and food. Third, breastfeeding should be separated from other fluid and food questions to capture the frequency and duration of nursing sessions offered during the illness. Research is also needed to assess the accuracy of the current zinc indicator to determine if caregivers are correctly recalling zinc treatment for current and recent diarrhea episodes.