Centro de Investigação em Saúde de Manhiça (CISM), Rúa 12, Vila da Manhiça, 1929, Maputo, CP, Mozambique.
Ministério da Saúde, Instituto Nacional de Saúde, Av. Eduardo Mondlane n° 1008, C.P, 264, Maputo, Moçambique.
BMC Infect Dis. 2019 Apr 15;19(1):322. doi: 10.1186/s12879-019-3948-9.
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).
Between December 2007 and November 2012, children under-five with MSD were enrolled in Manhiça 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 ~ 60 days post-enrolment was conducted and verbal autopsies performed in all death cases.
Of the 916 MSD-cases analyzed; 90% (821/916) completed 60 days 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 2 weeks 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).
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.
尽管儿童存活率有了显著提高，但腹泻导致的死亡人数仍然高得令人无法接受。我们旨在描述与腹泻相关的死亡率，并评估莫桑比克中度至重度腹泻（MSD）儿童死亡的风险因素。
2007 年 12 月至 2012 年 11 月期间，在全球肠道多中心研究（GEMS）中，五岁以下患有 MSD 的儿童在马希奇区入组。收集临床、流行病学和社会人口统计学特征。在招募时进行人体测量，并采集粪便样本。在入组后约 60 天进行随访访问，并对所有死亡病例进行口头尸检。
在 916 例 MSD 病例中，90%（821/916）完成了 60 天随访，69 例死亡。随访时的病死率为 8%（69/821），死亡率为每 1000 人周 10.2（95%CI：7.75-13.59）例死亡。研究参与者中近一半（48%，33/69）的死亡病例集中在腹泻发病后两周内。在单变量分析中，典型肠致病性大肠杆菌（典型 EPEC）和隐孢子虫分别与死亡风险增加相关（HR=4.16，p=0.0461）和（HR=2.84，p=0.0001）。相反，轮状病毒感染与死亡风险降低相关（HR=0.52，p=0.0198）。根据多变量分析，死亡的危险因素包括营养不良等合并症（HR=4.13，p<0.0001）、肺炎/下呼吸道感染（HR=3.51，p<0.0001）或侵袭性细菌病（IBD）（HR=6.80，p=0.0009）、入组时出现昏睡或明显无意识（HR=1.73，p=0.0302）或皮肤起皱（HR=1.71，p=0.0393），以及隐孢子虫感染（HR=2.14，p=0.0038）。当将分析限制在有可用 HIV 结果的人群（n=191，占总研究样本的 22%）时，HIV 被证明是死亡的一个显著危险因素（HR=5.05，p=0.0009）。对研究中的 100%死亡病例进行了口头尸检，强调腹泻是 39%（27/69）死亡的主要根本原因；其次是与 HIV/AIDS 相关的死亡 29.0%（20/69）和败血症 11.6%（8/69）。
针对隐孢子虫、营养不良和早期识别及治疗相关合并症的预防策略，可能有助于预防莫桑比克儿童与腹泻相关的大多数死亡。
