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Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd edition. Washington (DC): World Bank; 2006.

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Disease and Mortality in Sub-Saharan Africa. 2nd edition.

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Chapter 9Diarrheal Diseases

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Of the estimated total 10.6 million deaths among children younger than five years of age worldwide, 42 percent occur in the World Health Organization (WHO) African region (Bryce et al. 2005). Although mortality rates among these children have declined globally from 146 per 1,000 in 1970 to 79 per 1,000 in 2003 (WHO 2005), the situation in Africa is strikingly different. As compared with other regions of the world, the African region shows the smallest reductions in mortality rates and the most marked slowing down trend (figure 9.1). The under-five mortality rate in the African region is seven times higher than that in the European region. In 1980 this difference was equal to 4.3 times (WHO 2005).

Figure 9.1

Figure 9.1

Slowing Progress in Child Mortality (per 1,000 births) Source: Adapted from WHO 2005.

During the 1990s, the decline of under-five mortality rates in 29 countries of the world stagnated, and in 14 countries rates went down but then increased again. Most of these countries are from the African region (WHO 2005). A factor that may contribute to this situation is the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic in the region, but an underlying weakness of the implementation capacity of the health system is also likely to blame (Walker, Schwartländer, and Bryce 2002).

Similarly to all-cause mortality, global estimates of the number of deaths due to diarrhea have shown a steady decline, from 4.6 million in the 1980s (Snyder and Merson 1982) to 3.3 million in the 1990s (Bern et al. 1992) to 2.5 million in the year 2000 (Kosek, Bern, and Guerrant 2003). However, diarrheal diseases continue to be an important cause of morbidity and mortality worldwide, and despite all advances in health technology, improved management, and increased use of oral rehydration therapy (ORT) in the past decades, they remain among the five major killers of children under five years of age.

In contrast to mortality trends, morbidity due to diarrhea has not shown a parallel decline, and global estimates remain between two and three episodes of diarrhea per child under five per year. Kosek, Bern, and Guerrant (2003) estimated a global median incidence of diarrhea to be 3.2 episodes per child-year in the year 2000, similar to those found in previous reviews by Snyder and Merson (1982) and by Bern and colleagues (1992) as well as to those reported in the first edition of Disease Control Priorities in Developing Countries (Jamison et al. 1993).

This chapter reviews available information published since the 1980s on the morbidity and mortality burden of diarrheal diseases in children under five years of age in the WHO African region.

Methods

Reliable and comparable estimates of morbidity and mortality are difficult to obtain because of variations in methodology, failure to standardize case definitions of diarrhea, and seasonal nature of the disease, among other factors. Nevertheless, such estimates, mainly based on the available studies in the literature, are provided here.

HIV infection has added considerably to the burden of diarrheal diseases among adults and children. This is of particular importance in African countries that show high HIV prevalence. However, the scarcity of data makes it difficult to quantify comorbidity and its contribution to the mortality burden. Because of the probable influence of HIV/AIDS, especially in the mortality due to diarrheal disease, we have followed the WHO's division of the African region into two subregions, which takes into account mortality levels: the AFR D subregion (high child and high adult mortality) and the AFR E subregion (high child and very high adult mortality). Stratum E includes the countries in Sub-Saharan Africa where HIV/AIDS has had a substantial impact (Mathers et al. 2002). Specific estimates have been provided for each subregion whenever available data permitted. Countries included in each subregion are listed in appendix table 9A.1.

Table 9A.1. Regional Reporting Categories for Global Burden of Disease 2000: WHO African Subregions.

Table 9A.1

Regional Reporting Categories for Global Burden of Disease 2000: WHO African Subregions.

Data Sources and Literature Review: Morbidity

The usual sources of diarrhea morbidity data are either national surveys, such as Demographic and Health Surveys (DHSs) and the United Nations Children's Fund (UNICEF) Multiple Indicator Cluster Surveys (MICS, conducted from 1996 to 2000; http://www.childinfo.org/MICS2/Gj99306k.htm, accessed April 12, 2003), or the published literature.

The main limitation of using currently available national survey data to estimate diarrhea morbidity is the cross-sectional nature of data collection. The information obtained from these surveys is of diarrhea prevalence in the two weeks previous to the survey, which does not account for seasonality. Therefore, data are not comparable either across sites or over time. Moreover, there is a potential for important recall bias in such morbidity surveys (Boerma et al. 1991; Snow et al. 1993). Some of the major limitations of longitudinal studies are lack of representativeness, possible site bias, low frequency of surveillance visits, and recall bias.

Most reviews carried out so far (Bern et al. 1992; Kosek, Bern, and Guerrant 2003; Snyder and Merson 1982) have relied on published studies to estimate the incidence or prevalence of diarrheal disease. Some of the limitations of this type of study are the small number of data points and the lack of representativeness, given the specific sites where most studies are carried out.

The most recent morbidity review (Kosek, Bern, and Guerrant 2003) included five prospective studies from African countries, carried out between 1987 and 1990: two studies were from the AFR D subregion (Guinea-Bissau and Nigeria) and three from the AFR E subregion (Democratic Republic of Congo, Kenya, and Zimbabwe). These studies are listed in appendix table 9A.2.

Table 9A.2. Main Characteristics of the Studies Included in the Morbidity Review.

Table 9A.2

Main Characteristics of the Studies Included in the Morbidity Review.

Data Sources and Literature Review: Mortality

Nationally representative surveys such as the DHS do not usually report causes of death, but the number of diarrhea-associated deaths can be obtained from either vital statistics registration systems or from special study populations. From each of these sources, the proportion of deaths attributed to diarrhea can be estimated as well as diarrhea mortality rates. However, the representativeness and accuracy of the data vary according to the type of source and various study design features.

The main limitations of vital registration systems are underreporting of the number of deaths and miscoding of the causes of death. Most of the limitations described for the use of longitudinal studies for estimating morbidity also apply to mortality estimation, such as lack of representativeness, possible site bias, and misclassification of the causes of death.

The only countries in the African region for which there is some reported vital registration (VR) coverage are Mauritius, South Africa, and Zimbabwe. The coverage for Mauritius was reported to be 100 percent in the year 2000. Only 1.4 percent of all deaths among children under five were due to diarrhea in this country. The latest information available for South Africa and Zimbabwe (1996 and 1990, respectively) reported estimated coverage rates of less than 50 percent (http://www.who.int/whosis/mort/table4). Therefore, in the African region, most information on cause-specific mortality relies on special studies available in the literature.

The studies included in our review were identified by a systematic search of the scientific literature published since 1980, performed through the WHO's library on Medline/Pubmed using the following terms: Africa, mortality, different spellings of "diarrhea," and all terms combined. No restriction was placed on publication language. The reference sections of these studies were then reviewed to identify additional studies.

The review performed by Kirkwood (1991) for the previous edition of Disease and Mortality in Sub-Saharan Africa included data from cross-sectional studies and from national diarrhea programs. In the current review we have considered only longitudinal studies. Inclusion criteria were the following: studies carried out in countries from Sub-Saharan Africa, studies published from 1980 on, studies containing diarrhea-specific mortality data, studies containing a minimum of 25 total deaths, community-based studies with at least one year of follow-up, and a follow-up time multiple of 12 months to minimize seasonal effects.

Twenty-four studies were identified that met the above criteria and were therefore included in this review (appendix table 9A.3). They were carried out in 15 (33 percent) of the 46 countries of the African region: seven were carried out in countries from AFR D, and eight from AFR E. Figure 9.2 illustrates the countries and the sites in each country for which studies were available.

Table 9A.3. Main Characteristics of the Studies Included in the Mortality Review.

Table 9A.3

Main Characteristics of the Studies Included in the Mortality Review.

Figure 9.2

Figure 9.2

Sites with Available Under-Five Diarrhea Mortality Data Source: Authors.

The 24 longitudinal studies identified in the current literature represent an important increase in information when compared with the 7 available studies included in the previous review (Kirkwood 1991). There has been more than a threefold increase in the available literature of longitudinal studies reporting diarrhea mortality in Sub-Saharan Africa. This increase in the number of publications from Sub-Saharan Africa resulted in a doubled number of African countries for which diarrhea mortality data were available, thus adding to the precision of the current estimates.

Data Source and Literature Review: Etiology

Similarly to what was described for morbidity and mortality estimates, the main data source to estimate diarrheal etiology is the published literature. We conducted a search of papers published since 1990, using Medline/Pubmed; the terms used were as follows: Africa, Sub-Saharan Africa, diarrhea, etiology, epidemiology, and children. Different spellings as well as combinations of terms were also considered. In addition, we considered keywords for specific etiologies known to cause diarrhea in children. Articles published in languages other than English, Spanish, Portuguese, Italian, and French that did not have an English abstract were not included. Further sources were identified from cross-references, consultation with experts in the field, and use of the "related articles" link in PubMed.

We used the following inclusion criteria: studies carried out at community level, among outpatient and inpatient health services; studies that covered at least 12 months of surveillance; and studies in which one or more causes of diarrhea were identified through the use of standard laboratory procedures. Exclusion criteria were studies reporting diarrhea outbreaks, studies carried out among children with HIV/AIDS, studies reporting nosocomial infections, and studies carried out in day-care centers.

Thirty-four studies were identified that met the above criteria, covering 12 African countries, 6 from each of the two African subregions. These are listed in appendix table 9A.4.

Table 9A.4. Main Characteristics of the Studies Included in the Etiology Review.

Table 9A.4

Main Characteristics of the Studies Included in the Etiology Review.

Reviews and Estimations

In the 1980s Snyder and Merson (1982) reviewed 24 published studies in order to estimate morbidity and mortality from diarrheal disease. Three of these studies, carried out in the African region (Ethiopia, Kenya, and Nigeria), reported the annual number of episodes of diarrhea per child by age group.

In an attempt to update these estimates, Bern and colleagues (1992) reviewed articles published between 1980 and 1990. There were seven studies available for the African regions, covering three countries: The Gambia, Ghana, and Nigeria.

Kosek, Bern, and Guerrant (2003) included four studies from the African region in their review, which had been carried out in the Democratic Republic of Congo, Guinea-Bissau, Kenya, Nigeria, and Zimbabwe (appendix table 9A.2). Table 9.1 summarizes the results from these studies. Unlike mortality, estimates of morbidity due to diarrhea do not show a decline over time, according to the reviews carried out. Estimates remain consistent for all age groups for which data are available. However, the number of observations, varying from three to five, is low for all three studies, and the uncertainty that prevails because of this low number and the different sites where the studies were carried out should be taken into account when interpreting these data.

Table 9.1. Median Estimates of Episodes of Diarrhea per Child per Year in the African Region, by Age Group.

Table 9.1

Median Estimates of Episodes of Diarrhea per Child per Year in the African Region, by Age Group.

Because some of the mortality studies were carried out in more than one country or more than one point in time, they provided a total of 27 data points to be included in the analysis. More than 50 percent of these 27 data points showed proportions of diarrhea mortality between 12 percent and 17 percent; 19 out of the 27 data points (70 percent) had proportions between 12 percent and 19 percent; and only 8 data points provided proportions greater than 20 percent. Because of the skewness of the frequency distributions, we chose to use medians rather than means to calculate diarrhea proportional mortality for each African subregion.

We have used two different approaches to estimate the numbers and proportions of diarrhea deaths for Sub-Saharan Africa in the year 2000: calculation of simple medians for each African subregion and extrapolation from the regression of medians of diarrhea proportional mortality against time.

Simple Medians of Diarrhea Proportional Mortality

As a first approach to estimating the number of deaths due to diarrhea among children younger than five years of age in the African region for the year 2000, we applied the median of the proportions of diarrhea deaths to the total number of deaths among children under five in each of the two African subregions. These medians were similar for the two subregions: 17.7 percent (interquartile intervals [IQI] 12.7–24.5 percent) in AFR D and 17.6 percent (IQI 12.9–19.3 percent) in AFR E. The WHO estimates that approximately 4.3 million children under five died in Africa in the year 2000: 2.0 million in AFR D and 2.3 million in AFR E (WHO, unpublished data). Applying the proportion of diarrhea deaths estimated to have occurred among children under five in Sub-Saharan Africa in the year 2000 to the total number of deaths in these children in that same year yields an approximate total of 760,000 diarrheal deaths.

Proportions over Time

It has been suggested that at least for some countries diarrhea mortality has been declining over the past years, mostly due to the spread of ORT use (Baltazar, Nadera, and Victora 2002; Miller and Hirschhorn 1995; Victora et al. 1996; Victora et al. 2000). We thus examined the medians of the proportions for studies carried out in Sub-Saharan Africa in different time periods.

Because there were only two observations in the late 1970s, we disregarded data from this time period and examined the following time periods: 1980–84, 1985–89, and 1990–94. Figure 9.3 shows that there were virtually no changes in diarrhea proportional mortality (β = −0.055) in the African region over the years 1980–95. Indeed, the medians of the proportion of diarrhea deaths were equal to 16.6 percent in the early 1980s, 17.7 percent in the late 1980s, and 16.1 percent in the early 1990s. If the situation remains the same and no major changes have occurred during more recent years, for which no data were available, the proportion of diarrhea deaths in the year 2000 could be estimated to be equal to 16.2 percent. This corresponds to an estimated total of 700,000 deaths, similar to the estimate obtained with the simple median calculation.

Figure 9.3

Figure 9.3

Medians of Diarrheal Proportional Mortality among Children under Five in the African Region, 1980–95 Source: Authors, from studies listed in appendix table 9A.3.

When comparing the median data points observed in the African region with those from other developing regions of the world (figure 9.4), we note that although there was a steep decline in the proportions of diarrhea mortality in the other regions (β = −0.78), virtually no decline was observed in Sub-Saharan Africa. These observations correspond to an approximately 33 percent decline in the proportion of diarrheal deaths between 1980 and 1995 in the other developing regions of the world and basically no changes in the African region.

Figure 9.4

Figure 9.4

Medians of Diarrheal Proportional Mortality among Children under Five in the African Region and Other Developing Regions, 1980–95 Source: Authors, from studies listed in appendix table 9A.3.

Comparison of Estimates from Recent Reviews of the Burden of Diarrhea Mortality

Kosek, Bern, and Guerrant (2003) recently reviewed 30 studies from all developing regions of the world that had available data on diarrhea proportional mortality for children under five years of age and that were published in the 1990s. Ten of these studies were from the African region and covered seven different countries (five from AFR D and two from AFR E). The medians of the diarrhea proportional mortality were 23.2 percent in AFR D and 14.2 percent in AFR E. By applying these medians to the total number of deaths among children under five estimated by the WHO in each of the two subregions in the year 2000, estimates of 454,000 deaths for AFR D and 329,000 deaths for AFR E were obtained. These correspond to a total 783,000 deaths for the whole region.

Morris, Black, and Tomaskovic (2003) have also recently reviewed the literature on causes of death among children under five and used a metaregression model with some selected covariates to estimate the proportional distribution of under-five deaths by cause in Sub-Saharan Africa and South Asia. The authors predicted that 21.9 percent (95 percent CI, 15.5–28.2 percent) of all deaths of children up to four years of age in Sub-Saharan Africa in the year 2000 were due to diarrhea, corresponding to a total of 935,000 deaths attributable to diarrhea.

Table 9.2 summarizes the estimates obtained from the main approaches used in this review and from the recent work performed by Kosek, Bern, and Guerrant (2003) and Morris, Black, and Tomaskovic (2003) as well as from the WHO's most recent mean estimates for the period 2000–03 (WHO 2005). Given the uncertainty of the estimates due to the scarcity and limited representativeness of data, a reasonable and plausible range for the numbers and proportions of deaths due to diarrhea among children under five in Africa can be provided by summarizing different approaches from various methodologies and their respective results. The two estimates provided for AFR D were 354,000 (18 percent) and 454,000 deaths (23 percent) and those provided for AFR E were 329,000 (14 percent) and 405,000 deaths (18 percent). By reviewing the five available estimates for the total African region, we might conclude that approximately 750,000 deaths that occurred among children under five in the year 2000 were due to diarrhea, with a range of estimates that varied between 700,000 (WHO 2005) and 935,000 deaths (Morris, Black, and Tomaskovic 2003). Our estimates are similar to the 741,000 deaths estimated by WHO for the African region, and recently published in TheWorld Health Report (WHO 2005).

Table 9.2. Estimated Number and Proportion of Deaths Due to Diarrhea among Children under Five(thousands).

Table 9.2

Estimated Number and Proportion of Deaths Due to Diarrhea among Children under Five(thousands).

Our estimates of deaths from diarrhea among children in Sub-Saharan Africa relied on published epidemiological studies using mostly verbal autopsy methods and thus have limitations inherent in the type of data used, such as lack of representativeness and site bias, observations over time, misclassification of the causes of death, and comparability of data from different studies.

The locations of these studies were rarely representative of the entire country population, as they were usually conducted in populations that are either easy to access or have atypical mortality rates. Furthermore, using studies from a few countries to predict distributions for many countries or a region would require empirical external validation, which we were not able to perform because of the unavailability of other sources of data, such as vital registration data for Sub-Saharan Africa or nationally representative surveys that included causes of death. However, we have tried to stratify countries according to their mortality patterns, especially in what concerns mortality due to HIV/AIDS, to minimize discrepancies between them. Although the observations over time should be interpreted with caution because of the different sites where the studies were conducted, this problem was minimized by including a reasonable number of studies from different sites for each of the three time periods under observation, which should provide an average of the distribution of mortality in these sites. Also, it should be kept in mind that these estimates were summarized as one single observation over time for all of Sub-Saharan Africa, based on a few sites from some countries (figure 9.2). As countries often vary widely in many important socioeconomic and health aspects, summarizing data across countries of a region may obscure important differences.

Some studies of childhood deaths in developing countries have shown that causes of death established using verbal autopsy methods are not always consistent with diagnoses based on more complete clinical data (Kalter, Gray, and Black 1990; Mobley et al. 1996; Snow et al. 1992). However, the estimates of the cause-specific mortality fraction (proportions of deaths attributable to one cause) resulting from verbal autopsy studies may not necessarily be inaccurate, if misclassification is random.

Finally, the studies reviewed used different case definitions of diarrhea as a cause of death and different methods for assigning them, both of which limit their comparability. Any review that attempts to compile and summarize data from the published literature, especially those data that use both standard and nonstandard verbal autopsy as the means of ascertaining cause of death, faces these limitations. However, the thorough literature search and the restrictive inclusion criteria used in this review, such as population-based studies with follow-up time a multiple of 12 months and studies with at least 25 total deaths, ensured that the studies used for the current estimates consisted of the most valid information available.

Enteropathogens, such as rotavirus, entero-adherent pathogenic Escherichia coli (EAEC), and enterotoxigenic Escherichia coli (ETEC), have been identified as important pathogens in diarrheal diseases, and rotavirus, which causes severe complications of diarrhea, has been found to be the most prominent cause of death in the world (Bern and Glass 1994; Bishop 1994; Haffejee 1995).

The severity of the etiological agent can be assessed by the setting in which it was most frequently isolated (community, inpatients, or outpatients). Less severe agents would be more frequently found in community settings, whereas more severe ones should be more common in either outpatients or (mainly) inpatients. Median proportions of diarrheal episodes attributable to each major cause of diarrhea from community studies could therefore be applied to estimates of diarrhea morbidity to obtain episodes of diarrheal diseases by cause, and median proportions from inpatient studies could be applied to estimates of diarrhea mortality to calculate the number of diarrheal deaths by etiology. However, because of the scarcity of data available for the African region we did not pursue these calculations.

The studies included in the estimates of etiology by setting are listed in more detail in appendix table 9A.4. Table 9.3 shows the countries for which data on etiology were available by setting (community, inpatients, or outpatients).

Table 9.3. Available Etiology Data, by Country and Study Setting.

Table 9.3

Available Etiology Data, by Country and Study Setting.

Tables 9.4 and 9.5 present the estimated median of the proportions of etiological agents identified and corresponding IQI by study site for subregions AFR D and AFR E, respectively. In our review, Giardia lamblia was more frequently isolated among children with diarrhea in the community studies, whereas EAEC was mainly seen among outpatients. Rotavirus was the etiological agent most frequently isolated in both inpatient and outpatient health services. Therefore, it is likely that rotavirus is the leading cause of mortality due to diarrhea in Africa, as has been observed in other parts of the world. Coinfection of various agents was reported in 16 percent and 7 percent of community-level studies in AFR D and AFR E, respectively. Because our review did not include publications of diarrhea outbreaks, the magnitude of Vibrio cholerae, and Shigella dysenteriae type 1 is underrepresented in this review.

Table 9.4. Median of the Proportions of Etiological Agents among Children under Five in the AFR D Subregion, by Study Site.

Table 9.4

Median of the Proportions of Etiological Agents among Children under Five in the AFR D Subregion, by Study Site.

Table 9.5. Median of the Proportions of Etiological Agents among Children under Five in the AFR E Subregion, by Study Site.

Table 9.5

Median of the Proportions of Etiological Agents among Children under Five in the AFR E Subregion, by Study Site.

Our estimates of the distribution of diarrhea etiology among children in Sub-Saharan Africa relied on published epidemiological studies. The same limitations reported for the morbidity and mortality estimates therefore apply to these etiological estimates. Moreover, very few studies were identified through the literature search for the African region, and of those, not all have attempted to identify the whole set of etiological agents.

The Role of Risk Factors for Diarrheal Disease in the African Region

Broadly recognized risk factors for diarrheal diseases include little or no access to safe water and sanitation, as well as poor hygiene and feces disposal practices at home (Daniels et al. 1990; Haggerty et al. 1994; LaFond 1995; MacDougall and McGahey 2003). These and many other factors, such as poor housing and crowding, are intrinsically associated with poverty. Furthermore, poverty usually limits access to health care and restricts appropriate and balanced diets. Inequities in exposure and resistance add up to inequities in coverage of available preventive interventions, access to an appropriate health provider, and care, making poor children more likely to become sick than the better-off children (Victora et al. 2003).

Some studies have identified a few family characteristics as protective factors. These are monogamy of the father, defined residential area (Vaahtera et al. 2000), having a private kitchen, and being cared for by the mother (Oni, Schumann, and Oke 1991). These factors are of special importance in Sub-Saharan Africa, where the AIDS epidemic has led to an unprecedented number of orphans (about 12 million by the end of 2001) that is likely to more than double during this decade (Dabis and Ekpini 2002).

A WHO report on global water supply provides worrisome figures of current and future scenarios for Africa (WHO 2000). Of all the regions in the world, the African region was the only one showing a decline in the proportion of the population that had access to sanitation between 1990 and the year 2000 (figure 9.5).

Figure 9.5

Figure 9.5

Change in Sanitation Coverage by Region, 1990–2000 Source: WHO 2000.

Approximately 50 percent (300 million individuals) of the African population have no access to safe water, and 66 percent (400 million individuals) lack access to hygienic sanitation. It is expected that by the year 2020 these figures will rise to 400 million and 500 million, respectively.

Table 9.6 gives data on feces disposal practices at home in urban and rural regions of four African countries. Such practices have provided the rationale for more preventive interventions and are likely to explain the higher prevalence of diarrheal disease in rural areas. As in most developing regions of the world, African countries' poorest populations live in rural areas. Table 9.7 presents the medians of the prevalence of diarrheal disease according to urban and rural areas.

Table 9.6. Feces Disposal Practices at Home, by Urban and Rural Residences in Four African Countries(percent).

Table 9.6

Feces Disposal Practices at Home, by Urban and Rural Residences in Four African Countries(percent).

Table 9.7. Prevalence (Median) of Diarrheal Disease, the Two Weeks before Survey, by Urban and Rural Site of Residence in AFR D and AFR E(percent).

Table 9.7

Prevalence (Median) of Diarrheal Disease, the Two Weeks before Survey, by Urban and Rural Site of Residence in AFR D and AFR E(percent).

Some Additional Comments

There is an increasing concern that gender disparities might influence the distribution of ill-health and treatment, particularly in under-five girls. Some evidence suggests that girls in developing countries are prone to higher mortality and poorer nutritional status than boys (Helen Keller International 1994; Sundary 1986). In Sub-Saharan Africa, few prospective studies lasting at least one year report sex differences at the community level (Perch et al. 2001). Some prospective studies conducted in health facilities on outpatients (Gomwalk et al. 1993; Gomwalk, Gosham, and Umoh 1990) and inpatients (Mpabalwani et al. 1995; Steele et al. 1998) show that boys are more likely than girls to be taken to the facility because of diarrhea (boy-girl ratios are 2 to 1 and 4 to 1, respectively). However, nationally representative studies, such as the DHSs, conducted from 1987 to 2001 in several Sub-Saharan African countries show no significant sex differences for health care–seeking behavior and treatment received, whether it is given at home or at a health facility. Findings are summarized in table 9.8.

Table 9.8. Children under Five Taken to Health Facilities or Receiving Treatment for Diarrheal Disease in the Two Weeks before Survey, by Sex(percent).

Table 9.8

Children under Five Taken to Health Facilities or Receiving Treatment for Diarrheal Disease in the Two Weeks before Survey, by Sex(percent).

The African region has been a target of diarrheal epidemic outbreaks for several decades. One of the most dramatic manifestations of these outbreaks occurred in July 1994 among Rwandan refugees in Goma, Democratic Republic of Congo (formerly Zaire), when almost 50,000 refugees died during a diarrhea epidemic.

The African region has replaced the Indian subcontinent as the new home of V. cholerae. The seventh cholera pandemic that originated in Asia reached Africa in the early 1970s. In 2001 there were more than 170,000 reported cases of cholera, which represented 94 percent of the globally reported cases. From these, 2,590 people died. Nearly all countries in Sub-Saharan Africa now regularly report cases of cholera. Table 9.9 shows the reported number of cases and deaths from cholera in the world and in the African region between 1996 and 2001. These figures, however, need to be interpreted with caution, since countries that have endemic cholera appear not to have notified the WHO of any cases of cholera.

Table 9.9. Cases and Deaths Due to V. cholerae Reported to WHO, 1996–2001.

Table 9.9

Cases and Deaths Due to V. cholerae Reported to WHO, 1996–2001.

Early reports of Vibrio parahaemolyticus in gastroenteritis cases in Africa (Utsalo, Eko, and Antia-Obong 1991) have been confirmed to be associated with the O3:K6 pandemic strain (Ansaruzzaman et al. 2004; Chowdhury et al. 2000), documenting the extension of this pandemic into the region. S. dysenteriae serotype 1 has also been documented to cause outbreaks of dysenteric diarrhea in several African countries (Birmingham et al. 1997; Guerin et al. 2003; Malakooti et al. 1997), including in refugee camps (Paquet et al. 1995). These organisms are important causes of morbidity and mortality in diarrhea outbreaks among stable communities and more so in displaced populations or those affected by catastrophic events. The widespread use of antibiotics across all regions has increased the prevalence of antibiotic resistance in most bacterial enteropathogens, increasing the risk in the region of an outbreak of S. dysenteriae serotype 1 with multiresistant strains.

The Role of Interventions to Control Diarrheal Diseases

There is sufficient evidence that several interventions are effective in the prevention and treatment of diarrheal diseases (Jones et al. 2003). These interventions are exclusive breastfeeding, complementary feeding, safe water, good sanitation and hygiene, zinc and vitamin A supplementation, ORT, and antibiotics for dysentery. It is estimated that these interventions could prevent 22 percent of deaths due to diarrhea (Jones et al. 2003). Most of these interventions are feasible for implementation in low-income countries such as those in the African region; however, the capacity to deliver these important interventions effectively should be strengthened (Bryce et al. 2003). The availability of safe and effective rotavirus vaccines (Ruiz-Palacios et al. 2006; Vesikari et al. 2006), introduced in several countries in Latin America in 2005 are likely to complement these interventions, if effectively delivered. However, the stability of diarrhea rates observed in all reviews done since the 1980s shows that despite the reduction of diarrhea mortality, most likely through better case management, very little has been done to prevent the transmission of diarrheal diseases. The progress toward better water and sanitation observed in other regions has not yielded a reduction of diarrhea morbidity, suggesting that poor hygiene practices (Yeager et al. 1999) and the ingestion of contaminated food (Lanata 2003) may be the most important factors and where preventive interventions, like handwashing (Curtis and Cairncross 2003), should be promoted.

Conclusion

Despite data limitations in estimating accurate numbers of diarrhea cases and deaths, it becomes clear from the results of this and other reviews that diarrheal disease remains an important cause of morbidity and mortality among children under five years of age in the African region. As opposed to the declining trends in the proportion of diarrhea mortality in other developing regions of the world, virtually no decline has been observed in the African region since the early 1980s. Diarrheal diseases remain one of the major killers of children under five, being responsible for about 750,000 of a total of 4.3 million deaths of African children up to four years of age.

More important than the precision in the numbers and in the exact contribution of each pathogen to diarrhea morbidity and mortality are the patterns and trends shown in this review. The fact that almost 40 percent of all diarrhea deaths in children under five worldwide occur in the African region is striking. The diarrhea mortality burden among children under five in Sub-Saharan Africa reveals the persistent magnitude of this preventable and treatable disease in the region.

The efficacy of existing interventions to prevent or treat diarrheal diseases and to thereby reduce diarrhea mortality has been proved. Large reductions in child mortality could be achieved with their implementation. Therefore, careful planning and evaluation of interventions to control cases and deaths due to diarrhea will be important if under-five mortality is to be reduced and goal four of the Millennium Development Goals—to reduce under-five mortality by two-thirds by 2015, from the base year 1990 (United Nations 2000)—is to be achieved in the African region.

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Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank.
Bookshelf ID: NBK2302PMID: 21290663
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