Etiologies, Risk Factors and Impact of Severe Diarrhea in the Under-Fives in Moramanga and Antananarivo, Madagascar

<div><p>Background</p><p>Diarrheal disease remains a leading cause of death in children in low-income countries. We investigated the etiology, risk factors and effects on nutritional status of severe diarrhea in children from two districts in Madagascar.</p><p>Methods</p><p>We performed a matched case-control study in 2011 to 2014, on children under the age of five years from Moramanga and Antananarivo. The cases were children hospitalized for severe diarrhea and the controls were children without diarrhea selected at random from the community. Stool samples were collected from both groups. Anthropometric measurements were made during follow-up visits about one and two months after enrolment.</p><p>Results</p><p>We enrolled 199 cases and 199 controls. Rotavirus infection was the most frequently detected cause of diarrhea. It was strongly associated with severe diarrhea (OR: 58.3; 95% CI: 7.7–439.9), accounting for 42.4% (95% CI: 37.6–43.1) of severe diarrhea cases. At the household level, possession of cattle (OR = 0.3; 95% CI: 0.1–0.6) and living in a house with electricity (OR = 0.4; 95% CI: 0.2–0.8) were protective factors. The presence of garbage around the house was a risk factor for severe diarrhea (OR = 3.2; 95% CI: 1.9–5.4). We found no significant association between severe diarrhea and the nutritional status of the children at follow-up visits, but evident wasting at enrolment was associated with a higher risk of severe diarrhea (OR = 9; 95% CI: 4.5–17.9).</p><p>Conclusions</p><p>Severe childhood diarrhea is mostly caused by rotavirus infection. An anti-rotavirus vaccine has already been introduced in Madagascar and should be promoted more widely. However, post-licensing surveillance is required. Interventions to improve the nutritional status of children, preventive measures focused on household and personal hygiene and nutritional rehabilitation during severe diarrheal disease should be reinforced.</p></div

Clinical symptoms associated with the enteric pathogens isolated from children with diarrhea in Antananarivo and Moramanga, 2011–2014.

<p>Clinical symptoms associated with the enteric pathogens isolated from children with diarrhea in Antananarivo and Moramanga, 2011–2014.</p

Comparison of weight-for-height or length (WHZ) scores at enrolment, and change in WHZ (ΔWHZ/WHZ₀) between enrolment and follow-up at 30 and 60 days, between children with diarrhea and their matched controls from Antananarivo and Moramanga, 2011–2014.

<p>Comparison of weight-for-height or length (WHZ) scores at enrolment, and change in WHZ (ΔWHZ/WHZ₀) between enrolment and follow-up at 30 and 60 days, between children with diarrhea and their matched controls from Antananarivo and Moramanga, 2011–2014.</p

Individual and household characteristics of the cases and controls from Antananarivo and Moramanga, 2011–2014.

<p>Individual and household characteristics of the cases and controls from Antananarivo and Moramanga, 2011–2014.</p

Characteristics of patients and analysis of the risk factors.

<p>Characteristics of patients and analysis of the risk factors.</p

Antimicrobial resistance of ESBL-producing isolates (number of tested isolates in brackets).

<p>Antimicrobial resistance of ESBL-producing isolates (number of tested isolates in brackets).</p

Aetiological agents and co-infections among patients under 5 years old hospitalised for SARI, November 2010 to July 2012 in Antananarivo, Madagascar.

<p><i>RSV : Respiratory Syncitial Virus; IA : Influenza A; RhV : Rhinovirus; hMPV : human metapneumovirus;Co : coronavirus_co43/NL63/229E; BoV : Bocavirus; PiV : parainfluenza virus 1/2/3; Spn : Streptococcus pneumoniae; Hib : Haemophilus influenzae</i> de type b; <i>Sta : Staphylococcus aureus; Brc : Branhamella catharralis; S : Streptococcus mitis/sanguinis/G/D/equinis/Beta haemolitic; Aero.h : Aero hydromonas; Aeroc spp : Aerococcus spp; Pseu aer : Pseudomonas aeruginosa; List sp : Listeria sp; Ent.spp : Enterobacter spp; Kleb pn : Klebsiella pneumoniae; Ser Mar : Serritia marcescens; Mora sp : Moraxela species; Esch. c : Escherichia coli.</i></p

Outcome Risk Factors during Respiratory Infections in a Paediatric Ward in Antananarivo, Madagascar 2010–2012

<div><p>Background</p><p>Acute respiratory infections are a leading cause of infectious disease-related morbidity, hospitalisation and mortality among children worldwide, and particularly in developing countries. In these low-income countries, most patients with acute respiratory infection (ARI), whether it is mild or severe, are still treated empirically.</p><p>The aim of the study was to evaluate the risk factors associated with the evolution and outcome of respiratory illnesses in patients aged under 5 years old.</p><p>Materials and Methods</p><p>We conducted a prospective study in a paediatric ward in Antananarivo from November 2010 to July 2012 including patients under 5 years old suffering from respiratory infections. We collected demographic, socio-economic, clinical and epidemiological data, and samples for laboratory analysis. Deaths, rapid progression to respiratory distress during hospitalisation, and hospitalisation for more than 10 days were considered as severe outcomes. We used multivariate analysis to study the effects of co-infections.</p><p>Results</p><p>From November 2010 to July 2012, a total of 290 patients were enrolled. Co-infection was found in 192 patients (70%). Co-infections were more frequent in children under 36 months, with a significant difference for the 19–24 month-old group (OR: 8.0).</p><p>Sixty-nine percent (230/290) of the patients recovered fully and without any severe outcome during hospitalisation; the outcome was scored as severe for 60 children and nine patients (3%) died.</p><p>Risk factors significantly associated with worsening evolution during hospitalisation (severe outcome) were admission at age under 6 months (OR = 5.3), comorbidity (OR = 4.6) and low household income (OR = 4.1).</p><p>Conclusion</p><p>Co-mordidity, low-income and age under 6 months increase the risk of severe outcome for children infected by numerous respiratory pathogens. These results highlight the need for implementation of targeted public health policy to reduce the contribution of respiratory diseases to childhood morbidity and mortality in low income countries.</p></div

Patient characteristics and aetiologies according to outcome among patients under 5 years old hospitalized for SARI, November 2010 to July 2012, in Antananarivo, Madagascar.

*<p>Univarite analysis;</p>#<p>Multivariate analysis (variables with p<0.20 on univariate analysis).</p><p>–: reference variable.</p>**<p>Comorbitidy: congenital diseases, malnutrition, prematurity.</p>***<p>Atopic: including atopic food, drug, acaria pollen or asthma comorbidity.</p

Patient characteristics and main aetiologies according for mono- and co- infections among patients under 5 years old hospitalised for SARI between November 2010 and July 2012 in Antananarivo, Madagascar.

<p>P value: Fisher's exact test (univariate analysis), OR adjusted: multivariate analysis (variables with p<0.20 on univariate analysis).</p><p>–: reference variable.</p>*<p>♦Comorbitidy: congenital diseases, malnutrition, prematurity,</p>**<p>Atopic: including atopic food, drug, acaria pollen or asthma comorbidity.</p