Marie Kaniecki

EPID506

The Epidemiology of Diarrheal Diseases in Mali

The World Health Organization (WHO) defines Diarrhea as “the passage of three or more loose or

liquid stools per day (or more frequent passage than is normal for the individual)”1. Many different

pathogens cause diarrhea as a symptom, including bacteria such as Vibrio Cholerae, viruses such as

rotavirus, and parasites such as Giardia lamblia. The Global Enteric Multicenter Study (GEMS)

examined diarrheal diseases in children under five years of age at seven sites in Africa and Asia including

Bamako, Mali, and identified rotavirus, Cryptosporidium, enterotoxigenic Escherichia coli producing

heat-stable toxin, and Shigella as the pathogens causing the most attributable cases of moderate-to-severe

diarrhea2. Diarrheal diseases can become fatal, leading to severe dehydration if left untreated1. Non-fatal

cases still have lasting impact through contributions to malnutrition and impaired immunity3. These non-

fatal consequences create a cyclical effect, with malnutrition and impaired immunity leaving an individual

more susceptible to future episodes of diarrhea3.

Despite significant reductions in associated mortality and morbidity in the last few decades, diarrheal

disease remains the second leading cause of under-five mortality in the world1 and the third leading cause

of Disability Adjusted Life Years (DALYs) in sub-Saharan Africa and South Asia3. According to the

Institute for Health Metrics and Evaluation (IMHE), diarrheal disease is the second leading cause of death

in Mali for people of all ages4. It is also the second leading cause of premature death in terms of Years of

Life Lost (YLL) and the tenth leading cause of disability in terms of Years Lived with Disability (YLD)

in Mali4. However, the number of deaths attributed to diarrheal diseases decreased overall by 32.4% from

2005 to 2016 in Mali, showing some improvement4.

Children under age five are at high risk for both diarrheal disease and long-term nutritional

consequences stemming from diarrheal episodes5. Walker et al. modeled diarrheal disease incidence rates

in children under five in low- and middle-income countries (LMICs) using community-based cohort

studies. They found a U-shaped relationship between age and diarrheal disease with children 6-11 months

of age having the highest incidence, and an overall decline in incidence from 1990 to 2010 for all age
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groups worldwide and in Mali. In Mali in 2010, they reported an incidence rate of 4.07 episodes per

child-year for children aged 0-5 months, 6.21 episodes per child-year for children aged 6-11 months, 5.03

episodes per child-year for children aged 12-23 months, and 3.21 episodes per child-year for children

aged 24-59 months5. Bado et al. found children ages 6-36 months have the highest likelihood of

experiencing diarrheal disease and suggest children under 6 months may be less likely to experience

diarrheal disease in comparison due to direct benefits from maternal immunity6.

Breastfeeding practices significantly influence childhood prevalence of diarrhea. Children who

experienced early initiation of breastfeeding, exclusive breastfeeding, and predominant breastfeeding up

until one year of age had a lower risk of diarrheal disease in an analysis of Demographic and Health

Survey (DHS) data from Mali and eight other countries in sub-Saharan Africa8. In Mali, these surveys

collected information from a nationally representative, stratified, two-stage cluster sample6. Access to

improved water sources and sanitation led to a stronger protective effect of breastfeeding against diarrheal

disease8. Unfortunately, cultural factors, low socio-economic status, and home-birthing contribute to

suboptimal exclusive breastfeeding practices in many sub-Saharan African countries8.

Additional salient risk factors for diarrheal disease include access to improved water and different

types of sanitation facilities6,7. GEMS observed increased odds of moderate to severe diarrhea (MSD) in

children under five in households that shared sanitation facilities with other households7. The odds

increasing for sharing with more than 3 households versus 1-2 households, supporting the WHO’s

decision to classify shared sanitation facilities as unimproved due to predicted worse hygiene conditions

from sharing7. Since most households included in the GEMS had access to basic sanitation facilities, they

were unable to determine the comparative risks of shared sanitation facilities and open defecation7.

Access to improved water and sanitation is often tied to socioeconomic status and urbanicity. Of the

estimated 2.5 billion people worldwide without access to improved sanitation, 70% live in rural areas9.

The DHS data from 2001 and 2006 showed rural children were 1.3 and 1.5 times more likely to have a

diarrheal disease respectively6. Despite the WHO classifying shared sanitation facilities as unimproved,

an estimated 398 million people living in urban areas worldwide rely on shared facilities due to cost and
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limited space for private facilities7. Bado et al. reported several risk factors for diarrheal disease tied to

socioeconomic class, including maternal education, quality of the main floor material in the household,

type of latrine, and drinking water source, with a trend of increasing neighborhood inequities in diarrheal

disease over time6.

While diarrheal disease affects all socioeconomic classes, poorer Malians are disproportionately

burdened by the financial costs10, 11. GEMS found that wealth index was significantly associated with

MSD in Mali7. The highest wealth quintile spent the most money per household on diarrheal disease

treatment in children under five10. Since the proportion of cases incurring some cost did not vary among

wealth quintiles, a likely explanation is Malians with more disposable income can afford better or more

expensive treatment, and do not ration care the way those of a lower socioeconomic class often must 10.

The GEMS results suggest that girls may be disadvantaged when it comes to household decisions about

whether to seek care due to financial burden of care; direct and total costs for households were twice the

amount for boys than for girls despite no differences in MSD frequency between the sexes10.

GEMS attempted to quantify the economic burden of diarrheal episodes, albeit with a small sample

size compared to the base case-control study. GEMS estimated the direct medical, indirect medical, and

indirect (productivity loss) costs for households in Mali10. The mean cost per episode was $6.01 with 68%

of episodes incurring some cost, which is a significant amount for a recurring outcome in a country where

living on less than $1 per day is common10. The study attributed 53% of costs to direct medical expenses

(where the majority went toward medication specifically) and 42% of costs to indirect expenses or

productivity losses10. Of the three locations examined, Mali had the highest percentage of cost attributable

to direct medical costs. Of households that sought care outside of a hospital, 53% gave high treatment

costs as the primary reason, and 30% believed the child was not sick enough to warrant hospital care. Of

households that did not seek any form of care, 26.6% gave treatment and transportation costs as the

reason, and 10% cited a preference for traditional medicine10.

In Mali, the 2013 Global Burden of Diarrhea estimates place the percentage of DALYs in children

under five due to diarrhea between 10-15%13. However, the interaction between diarrheal disease and
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malnutrition contributes to significant loss of productivity and long-term consequences. In fact,

McCormick and Lang believe that the true burden of diarrheal disease is severely underestimated due to

an overemphasis on mortality versus long-term health outcomes in many estimates of diarrheal disease

burden in LMICs11. Common diarrheal causing pathogens may be present without overt diarrheal

symptoms, and the potential consequences of pathogens in the absence of diarrhea are not well

understood11. Diarrheal disease can negatively affect child growth and cognitive development, and

through malnutrition, lower immunity to other infections and reduce vaccine efficacy11. Thus, the burden

due to diarrheal disease is substantial, and diarrhea increases the burden of comorbid diseases as well11.

The majority of available diarrheal disease studies in Mali or sub-Saharan Africa only examine

diarrheal disease in children under five2, 5, 6. In addition, many studies focus on overall diarrheal disease

prevalence in sub-Saharan Africa and do not always provide breakdowns of the data at the country level.

While surveillance of diarrheal diseases is present in Mali through DHS, IMHE, and research studies such

as GEMS, poverty and political instability complicate data collection. In addition, many of the studies

cited use data, DHS or otherwise, collected prior to the start of civil unrest in early 2012. The 2012-2013

DHS only included southern Mali12. Furthermore, since most of the fatalities within the GEMS study

occurred outside of a health care facility, healthcare facility-based surveillance could miss cases when

people do not seek care10. The GEMS site in Mali was in Bamako2, where nearly 14% of the population

resides13. However, findings from this and other studies based in Bamako may not be generalizable to

rural populations, or other urban or periurban populations closer to current and former conflict zones. An

analysis of the geographic coverage of demographic surveillance systems found Southern Mali to be one

of the most poorly represented areas in sub-Saharan Africa14. The 2016 Global Burden of Disease study

rated the quality of data in Mali from 1980-2016 1 star out of 515. From 1980-1984, 4.3% of vital

registration or verbal autopsy data contained sufficient detail and from 1990-1994, 0.1% of vital

registration or verbal autopsy data contained sufficient detail; the remaining time intervals examined had

0.0% of vital registration or verbal autopsy data containing sufficient detail15.

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More recent and higher quality data would allow a better understanding of how conflict in Mali may

have influenced diarrheal disease mortality and morbidity. Conflict flared in Northern Mali when

insurgents clashed with government troops in early 2012, and along with a military coup deposing the

national government shortly after, exacerbated an ongoing humanitarian emergency precipitated by a

2011 drought. The conflict resulted in the United Nations suspending non-humanitarian aid to the

country. After the coup, floods plagued southern Mali in 2013, and the insurgent group National

Movement for Liberation of Azawad seized more northern territory, at one point controlling 2/3 of the

country’s area housing 15% of the Malian

population16. French troops helped recapture

most of the territory in 2013, only for territory

to continue changing hands between the

government and various Islamist groups17.

Though a peace accord was signed in 2015,

smaller scale attacks continue to contribute to

political instability17, 18.

Figure 1: Map of Mali showing rebel held cities in 201319.

Quantifying the overall impact of the conflict on diarrheal disease is difficult due to surveillance and

evaluation challenges during complex emergencies. Inadequate or absent data systems, social breakdown,

forced migration, underreporting and overreporting biases, and the chaos and confusion that stems from

the “fog of war”20 are only some issues facing public health researchers in conflict zones such as Mali. Of

the studies with data from after the onset of the conflict, Reiner et al. reported reductions in diarrheal

disease mortality rates of over 70% in the northern cities Timbuktu, Gao, Kidal, and the southern city
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Mopti from 2000 to 2015 despite the unrest21. Bado et al. found a slight increase in diarrheal morbidity

prevalence from the 2005-2009 cohort to the 2010-2015 cohort6. Ultimately, surveillance of diarrheal

disease and evaluation of interventions remain inadequate.

In 2012, UNICEF relief efforts included revitalizing improved water and sanitation sources and

health centers that had been destroyed or looted during the conflict. However, they refrained from

creating or improving new sources other than in schools or health centers to avoid creating new tensions

and due to the unpredictability of population flow16. The UNICEF report seemed optimistic regarding

containment of a cholera outbreak in the north shortly after the conflict began. Prevention efforts began 3

weeks prior to the outbreak and the outbreak was contained with 219 confirmed cases and 19 deaths16.

Though health infrastructure in conflict zones suffered most, displaced persons moving south placed

additional strain on existing infrastructure further south16. In 2017, UNICEF estimated the number of

displaced persons due to the conflict to be 59,000 with an additional 133,300 fleeing Mali entirely18.

Major Water, Sanitation, and Hygiene (WASH) interventions continue to be implemented and evaluated

despite the ongoing unrest, including programs for WASH in schools and WASH in health facilities18.

Mali established a national plan to attain Open Defecation Free Certification throughout the country by

2024, starting from the village level and moving up; Kouniana and Wola became the first two villages

certified open defecation free in 201718.

Zinc supplementation and oral rehydration salts (ORS) are often credited with the overall worldwide

reduction in diarrheal disease in the last several decades6. ORS and zinc treatments exist in Mali, but

coverage remains poor. Wilson et al. classified a targeted scale-up of ORS in Mali as a failure, since the

country only achieved a maximum ORS coverage of 15.7%22. Winch et al. identified high use of

unauthorized drug dealers and limited financial access to treatments as barriers to zinc supplementation

treatment in a pilot study in southern Mali23. Benefits of the introduction of zinc treatments included

increased care-seeking to community health workers for diarrheal episodes, increased use of ORS, and

decreased use of antibiotics for diarrheal episodes23. The rotavirus vaccine was incorporated as part of

Mali’s Expanded Program of Immunization (EPI) beginning in 201424. In the north, Timbuktu, Menaka,
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and Gao were found to have good general vaccine coverage, though data were not available for Kidal due

to insecurity18. UNICEF Mali further strengthened the EPI through capacity building for health workers

and use of solar power to improve vaccine refrigeration storage18. Unfortunately, rotavirus vaccine

coverage may be negatively affected by the pharmaceutical company Merck recently ending its

agreement to supply rotavirus vaccines at low cost25. The non-governmental organization (NGO) Muso,

based in Mali, has implemented a proactive community case management approach to case detection and

disease treatment for children under 512. A study of their intervention showed a steep reduction in all-

cause under five mortality in the periurban area where the intervention was implemented compared to

DHS estimates of other urban areas of Mali12. To follow the worldwide downward trend in child mortality

and morbidity from diarrheal disease, Mali must continue to improve WASH, address inadequacies of

healthcare infrastructure, and mitigate the effects of the northern conflict.

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24. Sow, S., Steele, A., Mwenda, J., Armah, G. & Neuzil, K. Reaching every child with rotavirus
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Kids. NPR (2018). at <https://www.npr.org/sections/goatsandsoda/2018/11/01/655844287/merck-
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