Estimating Diarrhea Mortality among Young Children in Low and Middle Income Countries

<div><h3>Background</h3><p>Diarrhea remains one of the leading causes of morbidity and mortality among children under 5 years of age, but in many low and middle-income countries where vital registration data are lacking, updated estimates with regard to the proportion of deaths attributable to diarrhea are needed.</p> <h3>Methods</h3><p>We conducted a systematic literature review to identify studies reporting diarrhea proportionate mortality for children 1–59 mo of age published between 1980 and 2009. Using the published proportionate mortality estimates and country level covariates we constructed a logistic regression model to estimate country and regional level proportionate mortality and estimated uncertainty bounds using Monte-Carlo simulations.</p> <h3>Findings</h3><p>We identified more than 90 verbal autopsy studies from around the world to contribute data to a single-cause model. We estimated diarrhea proportionate mortality for 84 countries in 6 regions and found diarrhea to account for between 10.0% of deaths in the Americas to 31.3% of deaths in the South-east Asian region.</p> <h3>Discussion</h3><p>Diarrhea remains a leading cause of death for children 1–59 mo of age. Published literature can be used to create a single-cause mortality disease model to estimate mortality for countries lacking vital registration data.</p> </div

Systematic review and data abstraction flow chart.

<p>Systematic review and data abstraction flow chart.</p

2008 Diarrhea Proportionate mortality among children 1–59 mo of age among countries^* without vital registration data compared to regional estimates from a multi-cause mixed model approach.

<p>*Countries Included in Single Cause Model: a) Algeria, Angola, Benin, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Cote d'Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Swaziland, Tanzania, Togo, Uganda, Zambia, Zimbabwe; b) Bolivia, Dominican Republic, Guatemala, Haiti, Honduras, Jamaica, Nicaragua, Paraguay; c) Afghanistan, Djibouti, Iraq, Morocco, Pakistan, Somalia, Sudan, Yemen; d) Azerbaijan, Georgia, Kyrgyz Republic, Tajikistan, Turkmenistan, Uzbekistan; e) Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Timor-Leste; f) Cambodia, China, Lao, People's Democratic Republic of Micronesia, Mongolia, Nauru, Papua New Guinea, Philippines, Samoa, Solomon Islands, Vanuatu.</p><p>**100% of deaths included in multi-disease mixed approach Multi-cause mixed methods approach. Uncertainty ranges for total number of diarrhea deaths from MC model have been previously presented <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0029151#pone.0029151-Black1" target="_blank">[5]</a>.</p

Logistic regression model parameter estimates.

<p>Logistic regression model parameter estimates.</p

Geographic distribution of model input data and countries for which the model predicts proportionate mortality.

<p>Geographic distribution of model input data and countries for which the model predicts proportionate mortality.</p

Comparison of country specific diarrhea-proportionate mortality estimates by country for the single cause-model vs. Lancet estimates [<b>5</b>].

<p>Comparison of country specific diarrhea-proportionate mortality estimates by country for the single cause-model vs. Lancet estimates <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0029151#pone.0029151-Black1" target="_blank">[<b>5</b>]</a>.</p

Distribution of study level diarrhea proportionate mortality by WHO region.

<p>Distribution of study level diarrhea proportionate mortality by WHO region.</p

Median age-adjusted proportions of causes of diarrhea, constrained to fit 100%, in 286 inpatients studies of children <5 years of age published between 1990–2011, by WHO region.

<p>Median age-adjusted proportions of causes of diarrhea, constrained to fit 100%, in 286 inpatients studies of children <5 years of age published between 1990–2011, by WHO region.</p

Median proportion of stool samples with rotavirus by mid study period.

<p>Median proportion of stool samples with rotavirus by mid study period.</p

Number of diarrheal deaths estimated for each pathogen in children 0–59 m of age in the world for the year 2011, using constrained median proportions to fit 100%.

<p>Number of diarrheal deaths estimated for each pathogen in children 0–59 m of age in the world for the year 2011, using constrained median proportions to fit 100%.</p