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

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 Manhica 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 similar to 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 60days 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 2weeks 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.