title: Diarrheal Disease in Rural Mozambique: Burden, Risk Factors and Etiology of Diarrheal Disease among Children Aged 0-59 Months Seeking Care at Health Facilities.
abstract: BACKGROUND
  Diarrheal disease remains a leading cause of illness and death, particularly in low-income countries. Its burden, microbiological causes and risk factors were examined in children aged 0-59 months living in Manhiça, rural southern Mozambique.
  
  
  METHODS
  Trends of diarrhea-related burden of disease were estimated during the period 2001-2012. A prospective, age-stratified and matched (by age, gender and geographical origin), case-control study was conducted during 2007-2011. Clinical, epidemiology, anthropometric measurement and fecal samples obtained from recruited children were used to estimate moderate-to-severe diarrhea (MSD) weighted attributable fractions.
  
  
  RESULTS
  Over the last decade the incidence of acute diarrhea has dropped by about 80%. Incidence of MSD per 100 child years at risk for the period 2007-2011 was 9.85, 7.73 and 2.10 for children aged 0-11, 12-23 and 24-59 months respectively. By adjusted population attributable fractions, most cases of MSD were due to rotavirus, Cryptosporidium, ETEC ST (ST only or ST/LT), Shigella and Adenovirus 40/41. Washing hands and having facilities to dispose child's stools were associated with a reduced risk of MSD, while giving stored water to the child was associated with an increased risk of MSD.
  
  
  CONCLUSIONS
  Despite the predominantly decreasing trends observed throughout the last decade, diarrheal diseases remain today a major cause of morbidity among children aged 0-59 months living in this rural Mozambican area. Rotavirus, cryptosporidium, Shigella, ETEC ST and Adenovirus 40/41 were the most important aetiologies of MSD. Thus, well-known preventive strategies such as washing hands, improving the treatment of stored water, having facilities to dispose children stools, and accelerating the introduction of the rotavirus vaccine should be promoted on a wider scale to reduce the current burden of diarrheal diseases.
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Tacilta
authors.initials: T
authors.lastname: Nhampossa
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Inacio
authors.initials: I
authors.lastname: Mandomando
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Sozinho
authors.initials: S
authors.lastname: Acacio
authors.affiliation: Barcelona Center for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.
authors.forename: Llorenç
authors.initials: L
authors.lastname: Quintó
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
authors.forename: Delfino
authors.initials: D
authors.lastname: Vubil
authors.affiliation: Barcelona Center for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.
authors.forename: Joaquin
authors.initials: J
authors.lastname: Ruiz
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
authors.forename: Delino
authors.initials: D
authors.lastname: Nhalungo
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
authors.forename: Charfudin
authors.initials: C
authors.lastname: Sacoor
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.
authors.forename: Arnaldo
authors.initials: A
authors.lastname: Nhabanga
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Ariel
authors.initials: A
authors.lastname: Nhacolo
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Pedro
authors.initials: P
authors.lastname: Aide
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique.
authors.forename: Sónia
authors.initials: S
authors.lastname: Machevo
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Betuel
authors.initials: B
authors.lastname: Sigaúque
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Abel
authors.initials: A
authors.lastname: Nhama
authors.affiliation: Center for Vaccine Development (CVD), University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Karen
authors.initials: K
authors.lastname: Kotloff
authors.affiliation: Center for Vaccine Development (CVD), University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Tamer
authors.initials: T
authors.lastname: Farag
authors.affiliation: Center for Vaccine Development (CVD), University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Dilruba
authors.initials: D
authors.lastname: Nasrin
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Barcelona Center for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.
authors.forename: Quique
authors.initials: Q
authors.lastname: Bassat
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique.
authors.forename: Eusebio
authors.initials: E
authors.lastname: Macete
authors.affiliation: Center for Vaccine Development (CVD), University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Myron M
authors.initials: MM
authors.lastname: Levine
authors.affiliation: Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Barcelona Center for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain.
authors.forename: Pedro
authors.initials: P
authors.lastname: Alonso
mesh_terms: D000208:Acute Disease; D000256:Adenoviridae / Q000302:isolation & purification; D001424:Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology; D016022:Case-Control Studies; D002675:Child, Preschool; D003457:Cryptosporidiosis / Q000453:epidemiology* / Q000469:parasitology; D003458:Cryptosporidium / Q000302:isolation & purification; D003967:Diarrhea / Q000453:epidemiology* / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D054307:Enterotoxigenic Escherichia coli / Q000302:isolation & purification; D005243:Feces / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D009073:Mozambique / Q000453:epidemiology; D011446:Prospective Studies; D012307:Risk Factors; D012401:Rotavirus / Q000302:isolation & purification; D012720:Severity of Illness Index; D012760:Shigella / Q000302:isolation & purification; D014777:Virus Diseases / Q000453:epidemiology* / Q000821:virology