Dataset Information

A Comparison of Diarrheal Severity Scores in the MAL-ED Multisite Community-Based Cohort Study.

ABSTRACT:

Objectives

There is a lack of consensus on how to measure diarrheal severity. Within the context of a multisite, prospective cohort study, we evaluated the performance of a modified Vesikari score (MAL-ED), 2 previously published scores (Clark and CODA [a diarrheal severity score (Community DiarrheA) published by Lee et al]), and a modified definition of moderate-to-severe diarrhea (MSD) based on dysentery and health care worker diagnosed dehydration.

Methods

Scores were built using maternally reported symptoms or fieldworker-reported clinical signs obtained during the first 7 days of a diarrheal episode. The association between these and the risk of hospitalization were tested using receiver operating characteristic analysis. Severity scores were also related to illness etiology, and the likelihood of the episode subsequently becoming prolonged or persistent.

Results

Of 10,159 episodes from 1681 children, 143 (4.0%) resulted in hospitalization. The area under the curve of each score as a predictor of hospitalization was 0.84 (95% confidence interval: 0.81, 0.87) (Clark), 0.85 (0.82, 0.88) (MAL-ED), and 0.87 (0.84, 0.89) (CODA). Severity was also associated with etiology and episode duration. Although families were more likely to seek care for severe diarrhea, approximately half of severe cases never reached the health system.

Conclusions

Community-based diarrheal severity scores are predictive of relevant child health outcomes. Because they require no assumptions about health care access or utilization, they are useful in refining estimates of the burden of diarrheal disease, in estimating the effect of disease control interventions, and in triaging children for referral in low- and middle-income countries in which the rates of morbidity and mortality after diarrhea remain high.

SUBMITTER: Lee GO

PROVIDER: S-EPMC5084640 | biostudies-literature | 2016 Nov

REPOSITORIES: biostudies-literature

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Publications

A Comparison of Diarrheal Severity Scores in the MAL-ED Multisite Community-Based Cohort Study.

Lee Gwenyth O GO Richard Stephanie A SA Kang Gagandeep G Houpt Eric R ER Seidman Jessica C JC Pendergast Laura L LL Bhutta Zulfiqar A ZA Ahmed Tahmeed T Mduma Estomih R ER Lima Aldo A AA Bessong Pascal P Jennifer Mats Steffi MS Hossain Md Iqbal MI Chandyo Ram Krishna RK Nyathi Emanuel E Lima Ila F IF Pascal John J Soofi Sajid S Ladaporn Bodhidatta B Guerrant Richard L RL Caulfield Laura E LE Black Robert E RE Kosek Margaret N MN

Journal of pediatric gastroenterology and nutrition 20161101 5

<h4>Objectives</h4>There is a lack of consensus on how to measure diarrheal severity. Within the context of a multisite, prospective cohort study, we evaluated the performance of a modified Vesikari score (MAL-ED), 2 previously published scores (Clark and CODA [a diarrheal severity score (Community DiarrheA) published by Lee et al]), and a modified definition of moderate-to-severe diarrhea (MSD) based on dysentery and health care worker diagnosed dehydration.<h4>Methods</h4>Scores were built usi ...[more]

PMID: 27347723

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Project description:BackgroundMost studies of the causes of diarrhoea in low-income and middle-income countries have looked at severe disease in people presenting for care, and there are few estimates of pathogen-specific diarrhoea burdens in the community.MethodsWe undertook a birth cohort study with not only intensive community surveillance for diarrhoea but also routine collection of non-diarrhoeal stools from eight sites in South America, Africa, and Asia. We enrolled children within 17 days of birth, and diarrhoeal episodes (defined as maternal report of three or more loose stools in 24 h, or one loose stool with visible blood) were identified through twice-weekly home visits by fieldworkers over a follow-up period of 24 months. Non-diarrhoeal stool specimens were also collected for surveillance for months 1-12, 15, 18, 21, and 24. Stools were analysed for a broad range of enteropathogens using culture, enzyme immunoassay, and PCR. We used the adjusted attributable fraction (AF) to estimate pathogen-specific burdens of diarrhoea.FindingsBetween November 26, 2009, and February 25, 2014, we tested 7318 diarrhoeal and 24 310 non-diarrhoeal stools collected from 2145 children aged 0-24 months. Pathogen detection was common in non-diarrhoeal stools but was higher with diarrhoea. Norovirus GII (AF 5·2%, 95% CI 3·0-7·1), rotavirus (4·8%, 4·5-5·0), Campylobacter spp (3·5%, 0·4-6·3), astrovirus (2·7%, 2·2-3·1), and Cryptosporidium spp (2·0%, 1·3-2·6) exhibited the highest attributable burdens of diarrhoea in the first year of life. The major pathogens associated with diarrhoea in the second year of life were Campylobacter spp (7·9%, 3·1-12·1), norovirus GII (5·4%, 2·1-7·8), rotavirus (4·9%, 4·4-5·2), astrovirus (4·2%, 3·5-4·7), and Shigella spp (4·0%, 3·6-4·3). Rotavirus had the highest AF for sites without rotavirus vaccination and the fifth highest AF for sites with the vaccination. There was substantial variation in pathogens according to geography, diarrhoea severity, and season. Bloody diarrhoea was primarily associated with Campylobacter spp and Shigella spp, fever and vomiting with rotavirus, and vomiting with norovirus GII.InterpretationThere was substantial heterogeneity in pathogen-specific burdens of diarrhoea, with important determinants including age, geography, season, rotavirus vaccine usage, and symptoms. These findings suggest that although single-pathogen strategies have an important role in the reduction of the burden of severe diarrhoeal disease, the effect of such interventions on total diarrhoeal incidence at the community level might be limited.

Project description:BackgroundClimate change threatens to undermine recent progress in reducing global deaths from diarrhoeal disease in children. However, the scarcity of evidence about how individual environmental factors affect transmission of specific pathogens makes prediction of trends under different climate scenarios challenging. We aimed to model associations between daily estimates of a suite of hydrometeorological variables and rotavirus infection status ascertained through community-based surveillance.MethodsFor this analysis of multisite cohort data, rotavirus infection status was ascertained through community-based surveillance of infants in the eight-site MAL-ED cohort study, and matched by date with earth observation estimates of nine hydrometeorological variables from the Global Land Data Assimilation System: daily total precipitation volume (mm), daily total surface runoff (mm), surface pressure (mbar), wind speed (m/s), relative humidity (%), soil moisture (%), solar radiation (W/m2), specific humidity (kg/kg), and average daily temperatures (°C). Lag relationships, independent effects, and interactions were characterised by use of modified Poisson models and compared with and without adjustment for seasonality and between-site variation. Final models were created with stepwise selection of main effects and interactions and their validity assessed by excluding each site in turn and calculating Tjur's Coefficients of Determination.FindingsAll nine hydrometeorological variables were significantly associated with rotavirus infection after adjusting for seasonality and between-site variation over multiple consecutive or non-consecutive lags, showing complex, often non-linear associations that differed by symptom status and showed considerable mutual interaction. The final models explained 5·9% to 6·2% of the variability in rotavirus infection in the pooled data and their predictions explained between 0·0% and 14·1% of the variability at individual study sites.InterpretationThese results suggest that the effect of climate on rotavirus transmission was mediated by four independent mechanisms: waterborne dispersal, airborne dispersal, virus survival on soil and surfaces, and host factors. Earth observation data products available at a global scale and at subdaily resolution can be combined with longitudinal surveillance data to test hypotheses about routes and drivers of transmission but showed little potential for making predictions in this setting.FundingBill & Melinda Gates Foundation; Foundation for the National Institutes of Health, National Institutes of Health, Fogarty International Center; Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins School of Medicine; and NASA's Group on Earth Observations Work Programme.

Project description:BackgroundEnvironmental enteropathy (EE), the adverse impact of frequent and numerous enteric infections on the gut resulting in a state of persistent immune activation and altered permeability, has been proposed as a key determinant of growth failure in children in low- and middle-income populations. A theory-driven systems model to critically evaluate pathways through which enteropathogens, gut permeability, and intestinal and systemic inflammation affect child growth was conducted within the framework of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) birth cohort study that included children from eight countries.MethodsNon-diarrheal stool samples (N=22,846) from 1253 children from multiple sites were evaluated for a panel of 40 enteropathogens and fecal concentrations of myeloperoxidase, alpha-1-antitrypsin, and neopterin. Among these same children, urinary lactulose:mannitol (L:M) (N=6363) and plasma alpha-1-acid glycoprotein (AGP) (N=2797) were also measured. The temporal sampling design was used to create a directed acyclic graph of proposed mechanistic pathways between enteropathogen detection in non-diarrheal stools, biomarkers of intestinal permeability and inflammation, systemic inflammation and change in length- and weight- for age in children 0-2years of age.FindingsChildren in these populations had frequent enteric infections and high levels of both intestinal and systemic inflammation. Higher burdens of enteropathogens, especially those categorized as being enteroinvasive or causing mucosal disruption, were associated with elevated biomarker concentrations of gut and systemic inflammation and, via these associations, indirectly associated with both reduced linear and ponderal growth. Evidence for the association with reduced linear growth was stronger for systemic inflammation than for gut inflammation; the opposite was true of reduced ponderal growth. Although Giardia was associated with reduced growth, the association was not mediated by any of the biomarkers evaluated.InterpretationThe large quantity of empirical evidence contributing to this analysis supports the conceptual model of EE. The effects of EE on growth faltering in young children were small, but multiple mechanistic pathways underlying the attribution of growth failure to asymptomatic enteric infections had statistical support in the analysis. The strongest evidence for EE was the association between enteropathogens and linear growth mediated through systemic inflammation.FundingBill & Melinda Gates Foundation.

Dataset Information

A Comparison of Diarrheal Severity Scores in the MAL-ED Multisite Community-Based Cohort Study.

Objectives

Methods

Results

Conclusions

Publications

A Comparison of Diarrheal Severity Scores in the MAL-ED Multisite Community-Based Cohort Study.

Similar Datasets

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