Open Journal of Epidemiology, 2021, 11, 207-221

https://www.scirp.org/journal/ojepi
ISSN Online: 2165-7467
ISSN Print: 2165-7459

Diarrhea Disease among Children under 5

Years of Age: A Global Systematic Review

Winfred Mbinya Manetu* , Stephen M’masi, Charles W. Recha

Department of Geography, Egerton University, Nakuru, Kenya

How to cite this paper: Manetu, W.M., Abstract

M’masi, S. and Recha, C.W. (2021) Diarr-
hea Disease among Children under 5 Years Diarrhea diseases remain the second leading cause of death among children
of Age: A Global Systematic Review. Open under five years globally. Nearly one in every five child deaths, about 1.6 mil-
Journal of Epidemiology, 11, 207-221. lion each year, are due to diarrhea. Further, diarrhea kills more young child-
https://doi.org/10.4236/ojepi.2021.113018
ren than malaria, measles and Acquired Immunodeficiency Syndrome
Received: May 21, 2021
(AIDS) combined. As a result, better understanding of childhood diarrhea
Accepted: June 25, 2021 occurrence can perhaps help reduce associated morbidity and mortality rates.
Published: June 28, 2021 Therefore, this study conducted a global systematic review on occurrence of
childhood diarrhea. The broad objective of this study was to review present
Copyright © 2021 by author(s) and
and past researches on childhood diarrhea and most importantly for children
Scientific Research Publishing Inc.
This work is licensed under the Creative under 5 years of age. The review focused on understanding the burden of di-
Commons Attribution International arrhea, causes of childhood diarrhea and solutions to the disease. A systemat-
License (CC BY 4.0). ic literature review was conducted using the databases of PubMed, CINAHL,
http://creativecommons.org/licenses/by/4.0/ Web of Science and Google Scholar. Search key terms used were childhood
Open Access
diarrhea, risk factors and intervention practices. Journal articles and related
reports were filtered and limited from 2005 to 2020. Sixty-one reports and ar-
ticles that met inclusion criteria were used in this review. Review found that,
childhood diarrhea imposes economic costs on the health system and fami-
lies. Also, repeated bouts of diarrhea can lead to malnutrition, stunting and
delayed brain growth later in life and can lead to stress and tension to the af-
fected households. The dependence on open water sources which are often
contaminated with fecal materials was found as the major cause of the rising
prevalence of childhood diarrhea. Other important factors were poor hygienic
practices and lack of sanitation facilities contribute to the spread of diarrhea
diseases. Improvements in the quality of drinking water, sanitation facilities
and hygiene practices especially in low and middle income countries have
been suggested by many studies as an intervention to reduce childhood di-
arrhea.

Keywords
Diarrhea, Risk Factors, Children under 5 Years, Intervention Measures

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W. M. Manetu et al.

1. Introduction
Diarrhea among children is defined as a disease with loose or watery stool three
or more times during a 24-hour period, or a decrease in the consistency of the
stool from that which is normal for the patient [1]. Though most episodes of
childhood diarrhea are not always severe, acute cases can lead to significant fluid
loss and dehydration. Consequently, deaths or other severe consequences can
arise if fluids are not replaced at the first sign of diarrhea. Diarrhea is a disease
caused by a wide range of pathogens, including, viruses, protozoa and bacteria
[2]. There are several most life-threatening viral and bacterial pathogens affect-
ing individuals in developing countries among them is rotavirus which is the
leading cause of acute diarrhea, and is responsible for about 40 per cent of all
hospital admissions due to diarrhea among children under five worldwide [3].
Major bacterial pathogens are E. coli, Shigella, Campylobacter and Salmonella
[2]. Cryptosporidium has been the most frequently isolated protozoan pathogen
among children and is frequently found among HIV-positive patients. Though
cholera is often thought of as a major cause of child deaths due to diarrhea, most
cases occur among adults and older children. According to World Health Or-
ganization (2008), Vibrio cholerae is endemic in multiple locations, including
Africa and Asia, and is a cause of large-scale outbreaks [4].
According to [5], for the purpose of optimal case management and of epide-
miological tracking, a diarrheal episode is often diagnosed according to symp-
toms and is classified into three categories: Acute watery diarrhea including
cholera is associated with significant fluid loss and rapid dehydration in an in-
fected individual. It usually lasts for several hours or days [6]. The pathogens
that generally lead to acute watery diarrhea include V. cholerae or E. coli bacte-
ria, as well as rotavirus. Bloody diarrhea, often referred to as dysentery, is
marked by visible blood in the stools [6]. It is associated with intestinal damage
and nutrient losses in an infected individual. The most common cause of bloody
diarrhea is Shigella, a bacterial agent that is also the most common cause of se-
vere cases and persistent diarrhea is an episode of diarrhea, with or without
blood that lasts at least 14 days. Undernourished children and persons with oth-
er illnesses such as AIDS, are more likely to develop persistent diarrhea, which in
turn, tends to worsen their condition [7].
Diarrhea remains the second leading cause of death among children under
five years globally after pneumonia (Table 1). It accounts for nearly 1.3 million
deaths a year among children under 5 years of age making it the second most
common cause of childhood mortality globally [8]. According to WHO and
UNICEF (2009), childhood diarrhea kills more young children than Acquired
Immunodeficiency Syndrome (AIDS), malaria and measles combined [7]. In ad-
dition, an estimated 2.5 billion cases of diarrhea occur every year among child-
ren under five years of age, and estimates suggest that overall incidence has re-
mained relatively stable over the past two decades [4]. Surprisingly, nearly three
quarters of child deaths due to diarrhea occur in just 15 countries (Table 2).

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 W. M. Manetu et al.

Table 1. Cause-specific deaths among children under five years of age worldwide [7].

Disease Pneumonia Diarrhea Neonatal causes Malaria measles AIDS Others

Percentage
17% 16% 37% 4% 4% 2% 4%
of deaths

Table 2. Distribution of diarrhea cases among children under 5 years of age by country
[7].

Total number of annual child deaths

Rank Country
rank country due to diarrhea

1 India 386,600

2 Nigeria 151,700

3 Democratic Republic of the Congo 89,900

4 Afghanistan 82,100

5 Ethiopia 73,700

6 Pakistan 53,300

7 Bangladesh 50,800

8 China 40,000

9 Uganda 29,300

10 Kenya 27,400

11 Niger 26,400

12 Burkina Faso 24,300

13 United Republic of Tanzania 23,900

14 Mali 20,900

15 Angola 19,700

According to World Health Organization 2009, India is the country that has the
highest childhood diarrhea prevalence with more than 380,000 children die from
diarrhea and its complications. However, India has made steady progress in re-
ducing deaths in children under 5 years where this reduction has been possible
due to inception and success to many universal programs such as expanded
programs on immunization. Despite the decline, the proportional mortality ac-
counted by diarrhea in India still remains high [9].
In Africa the burden of diarrhea remains high. Diarrhea disease remains the
third leading cause of disease and death in children younger than 5 years of age.
Diarrhea disease in Africa was responsible for an estimated 30 million cases of
severe diarrhea and 330,000 deaths in 2015 [10]. Where, the frequency and se-
verity of diarrhea in Africa is aggravated by lack of access to sufficient clean wa-
ter, poor sanitation and hygiene practices. Additionally, in Kenya diarrhea dis-
eases remains to be among the major public health problems where the mortality
rate of children under the age of five years due to diarrhea is very high about
16% surpassing deaths from HIV and Malaria combined [11]. Further, accord-
ing to KNBS and ICF Macro 2014, every child in Kenya under the age of five ex-

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W. M. Manetu et al.

periences an average of three bouts of diarrhea every year [12]. This is mostly
associated with poor hygiene practices, poor sanitation facilities as well as poor
supply of safe and clean drinking water where over 50% of hospital visits in
Kenya for illnesses are related to Water, Sanitation and Hygiene (WASH).
Consequently, this study presents comprehensive information on diarrhea
disease of under 5 years of age children by reviewing related past and present
empirical studies. The review reveals vital information that can help to under-
stand the burden of childhood diarrhea disease occurrence. Specifically, the
study gives detailed review of childhood diarrhea disease contributable factors
and appropriate intervention measures that can be used to prevent incidences of
childhood diarrhea. Finally, the study gives the gaps and recommendation of the
reviewed studies.

2. Methodology
This article is based on global review of both published and unpublished litera-
ture related to diarrhea disease among children under 5 years of age. Relevant
published articles and reports were identified by using international databases
including Google scholar, PubMed, Web of Science, China National Knowledge
Infrastructure and Science Direct. Search key terms included: Childhood diarr-
hea, risk factors and intervention practices. Published articles and reports were
limited from years 2005 to 2020. Sixty-one reports and journal articles reporting
the prevalence and determinants of diarrhea among under-five children and met
inclusion criteria were used to analyze the situation of global diarrhea.

3. Discussion
3.1. Burden of Childhood Diarrhea
Diarrhea disease is a global burden. According to [13], diarrhea is one of the
most common childhood illnesses, in both developing and developed countries.
While the disease is rarely a cause of death in developed countries, it is estimated
that approximately 1.6 million children die each year from diarrhea in the de-
veloping world [13]. Countries in sub-Saharan Africa and South Asia account
for almost 90% of global diarrheal deaths in children and a significant share of
the total disease burden [13]. Evidence shows that diarrhea diseases dispropor-
tionately affect locations with poor access to health care, safe water, and sanita-
tion, and low-income or marginalized countries [14]. For instance, in Kenya
which as a low income country, diarrhea disease is a public health burden and
remains among the top ten causes of under-five mortality and morbidity cases
[15] with other African countries like Ethiopia and Somalia still experiences
childhood diarrhea burden [16] [17] [18] [19] [20].
Further, repeated bouts of diarrhea can place a physical and emotional burden
on the primary mothers or caregivers since they are responsible for all tasks in
and around the household including the duty of caring for their children. A
study that was done to survey the Caregivers Opinions and Perceptions of

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 W. M. Manetu et al.

Workload in the Intensive Care Unit [21] reported they spend about 30% of
their workday in their households cleaning diarrhea. In the study, respondents
reported that more than two caregivers were needed to clean diarrhea 70% of the
time and 69% stated that this help was most often available. Unfortunately, staff
examined reported that, they felt a lot of frustrations from cleaning diarrhea for
about 50% of their time [21].
In addition to this, diarrhea can cause stress and tension in the households
because of inflated financial costs related to efforts to cope with the illness. A
study that was done in Rwanda to understand the economic burden attributable
to a child’s inpatient admission for diarrhea disease concluded that, households
often bear the largest share of the economic burden attributable to diarrhea hos-
pitalization and the burden can be substantial and especially for households in
the lowest income quintile [22]. In addition to this, the complexity of diarrhea
and the increasing cost of treatment puts additional burden on the health sector.
This is showed in studies done in countries like in Kenya, where the costs of care
and treatment for rotavirus gastroenteritis are high and rotavirus diarrhea leads
to considerable resource utilization in health care settings and the society [23].
In Kenya, diarrhea infection causes 4471 deaths, 8781 hospitalizations, and
1,443,883 clinic visits for diarrhea among children under 5 years of age annually.
Nationally, rotavirus disease in Kenya costs the health care system $10.8 million
annually. Similarly, a study conducted in Ghana in hospital health care to de-
termine the cost of diarrheal disease in northern Ghana [24], where the diarrhea
associated costs were found to be high. A study carried out in 3 south Asia set-
tings (Bangladesh, India and Pakistan) to estimate the costs borne by households
due to childhood diarrhea, including direct medical costs, direct nonmedical
costs, and productivity losses showed that childhood diarrhea creates economic
burden for affected households [25]. According to the study, mean cost per di-
arrhea episode was $1.82 in Bangladesh, $3.33 in India, and $6.47 in Pakistan
where majority of costs for households were associated with direct medical costs
from treatment [25].
Additionally, diarrhea among children younger than 5 years can lead growth
faltering and can cause long-term disability. This is evidenced by a study done in
assessing the non-fatal burden of childhood diarrhea where the study found out
that diarrhea significantly increased the risk of subsequent physical growth and
cognitive development impairment in the area [26]. The explanation of this is
that, in malnourished children, exposure to multiple bouts of diarrheal illnesses
may impair intestinal function. Persistent diarrhea has been also found to se-
riously affect nutritional status, growth, and intellectual function [27]. Other
evidences show that childhood diarrhea, especially in the first 2 years of life, can
negatively affect nutrient absorption, leading to poor physical growth [14] [28]
[29].

3.2. Childhood Diarrhea Risk Factors

There are several factors that have been assessed to influence the occurrence of

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W. M. Manetu et al.

childhood diarrhea. These are broadly categorized as socio-economic (mother’s

age, number of children, occupation status, household size and education level),
environmental (sources of drinking water, toilet facilities, water treatment) and
behavioral (bottle feeding and hand washing with soap). Several studies have
found that socioeconomic variables play a significant role in explaining the pre-
valence of childhood diarrhea. For example, studies that were done in Pakistan
and in Mogadishu Somalia, found that children of more educated mothers or
caregivers tend to have lower diarrhea prevalence, irrespective of water and sa-
nitation conditions and this is because of better understanding of proper hygiene
practices and correct feeding practices [20] [30]. Similarly, other studies done in
Ghana and Kenya reported that childhood diarrhea occurrence was significantly
lower where mothers had secondary education, compared to mothers with no
education [31] [32]. This is similar to a study in Ethiopia which found out that,
diarrhea cases among children under the age of 5 years were 3.97 times higher
among children of mothers/caretakers who had not attended formal education
compared with children whose mothers had attended formal education. This is
similar to studies by [1] [33] which showed that mother’s education was a sig-
nificant determinant of childhood diarrhea. Another important socioeconomic
factor which have been found to influence childhood diarrhea is occupational
status of the mother/caregiver. A study conducted in Pakistan by [30] found that
housewives mothers had more correct feeding practices as compared to em-
ployed mothers. The explanation of this being that, working mothers may find it
difficult to manage their time for preparation of health nutritious meals and ra-
ther prefers pre-formed meal for their young ones thus weakening the immune
system which leads to an increased susceptibility of children to diarrhea diseases
and other infections. Other socio-demographic variables that significantly pre-
dicted lower diarrhea incidence among children under five included: higher
household income [33], age of the child [1] [34] and the child’s sex [34]. Anoth-
er study found that children’s gender and age to be a critical determinant of di-
arrhea incidences. This was evidenced on a study by [35], where girls more
careful and practiced hand washing better than boys while older children prac-
ticed hand washing with soap much better than younger ones because they know
the dangers. Number of children in a household was also found to be a factor
contributing to childhood diarrhea. A study done in Ethiopia [17], reported that
children from households with more than three under-five children were four
times at risk of diarrhea compared to two or less under-five children in the
households. This is because when there are fewer number of under-five children
in the household’s mothers/caregivers are influenced to provide adequate and
timely childcare that with higher number of children where mothers might have
difficulties for taking care of a large number of children. These findings are sim-
ilar to another study in Nyeri county [32].
A number of studies found association between environmental variables as
intervening variable explaining childhood diarrhea incidence. For example,

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 W. M. Manetu et al.

non-protected sources of drinking water have been significantly associated with

an increased risk of diarrhea in a number of studies [36] [37]. The explanation of
this being that, unprotected water sources get easily contaminated by runoff
making the water unbiologically safe for drinking. Another study found child-
care institutions which used water from rains and shallow wells had 86.7% di-
arrheal diseases [34]. Other studies have identified the availability of latrine
among households to reduce childhood diarrhea [32] [36] [37]. A study in Gha-
na found that children who lived in in-house built toilets were 50% less likely to
contract diarrhea diseases than those who used outside toilets [38]. According to
the results of a study done in Dale district in Ethiopia reported that, the odds of
having diarrhea diseases among children under the age of 5 years were 3.23
times higher among children from households that disposed refuse improperly
compared with the odds of diarrheal diseases among children from households
which properly disposes of refuse [39]. This is because refuse may contain dif-
ferent pathogens which can cause diarrhea diseases and also creates a suitable
site for insects breeding. As a result, improper refuse disposal may increase the
chance of contact of insect vectors from refuse to food items worsening sanita-
tion and hygiene of entire family.
An association between maternal hygiene and behavioral variables and rates
of childhood diarrhea has also been demonstrated in number of studies. For in-
stance, a study that was conducted in Kenya found that, hand washing using
soap after toilet increase reduced diarrheal diseases [34]. A study in Dejen Dis-
trict, Ethiopia found out that, children from mothers who washed their hands
with water only were nearly twice more likely to develop diarrhoeal disease when
compared to those children whose mothers had hand washing practice with wa-
ter and soap/ash [36]. This is similar to a study done in Arba Minch which re-
ported that mothers with poor hand washing practices were significantly asso-
ciated with childhood diarrhoeal disease [1]. Immunization of children has also
been found to be a significant factor in explaining the childhood diarrhea inci-
dence. A study in Nyarugenge district, Rwanda found that children who had not
been vaccinated for Rotavirus were 8 times more likely to develop diarrheal dis-
eases than to those who were vaccinated [31]. Also, house floor material has
been found to significantly affect the occurrence of childhood diarrhea. A study
done in Dale district in Ethiopia showed that, developing diarrheal diseases
among children under the age of 5 years were 3.22 times higher among children
dwelling in Mud floor households as compared with children whose household
dwelling was with cement floor [39]. And the explanation of this could be due to
housing with cement floor is considered as a clean home environment. Accord-
ing to a study in Zana district in Ethiopia found that child feeding practices were
also significantly associated with childhood diarrhea in which children who did
not exclusively breastfeed and initiated complementary feeding above 6 months
of age were five and two-folds at risk of diarrhea, respectively compared to their
counterparts [17]. These findings are in agreement with similar findings done
elsewhere in Mecha District, Ethiopia [31].

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W. M. Manetu et al.

A brief summary on factors reported to influence childhood diarrhea is as

shown (Figure 1).

3.3. Diarrhea Intervention Practices

Many studies have been carried out to investigate on intervention measures that
can be undertaken to reduce childhood diarrhea. Washing hands with soap, in-
creasing access to safe water for drinking, improving water quality at the source,
treating household water and storing it safely and disposing of human excreta in
a sanitary manner to avoid contamination cases are among prevention practices
found to reduce number of childhood diarrhea cases. For instance, improving
sanitation facilities has been associated with a reduction in diarrhea incidence
across reviewed studies [40] [41]. The implication of this is that, improvements
of sanitation facilities can reduce the transmission of pathogens that cause di-
arrhea by preventing human fecal matter from contaminating environments.
Providing formal education to mothers or caregivers also helps reduce the cases
of childhood diarrhea. This could be explained by maternal educational status
persuades the personal and environmental hygienic practices, child feeding and
caring practices, improving living conditions and reducing resistance for new
ways of delivery for prevention and control of communicable diseases interven-
tions like health extension programs [17]. Washing one’s hands with soap is
another important barrier to transmission and has been cited as one of the most
cost-effective intervention for reducing incidence of diarrhea among children
under 5 years. Similarly, a number of studies [41] [42] [43] have shown that

Figure 1. Determinants of diarrhea among under five years.

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 W. M. Manetu et al.

handwashing with soap can reduce the incidence of childhood diarrhea disease.
In agreement with this study, another study also reported as handwashing with
soap particularly before eating, preparing food and feeding children and after
using the toilet can considerably reduce the risk of diarrhea [18]. This is can be
explained as soap breaks down grease and dirt that carry germs and dis-
ease-causing pathogens [18].
Additionally, access to plentiful water has been also shown to encourage better
hygiene, handwashing in particular, although the extent to which access to im-
proved water sources reduces diarrhea rates often depends on the type of water
source available (such as public taps or standpipes, protected dug wells or bore-
holes) [40] [44]. Further, interventions to improve water quality at the source,
along with treatment of household water and safe storage systems have been
shown to reduce diarrhea incidence. Proven and field-tested household water
treatment options that are currently being promoted include chlorination, filtra-
tion, combined flocculation and disinfection, boiling, and solar disinfection [43]
[45] [46] [47]. Household water treatment could potentially be scaled up quickly
and inexpensively in both development and emergency situations. It has even
become common practice in large cities where homes are connected to a mu-
nicipal water supply, since water is often polluted between the source and the
point of use. In addition to this, ensuring a clean home environment for the
children has been also found critical in reducing the transmission of pathogens
that cause diarrheal diseases [39].
Regarding maternal/caregiver health and caring practices, proper breastfeed-
ing and appropriate timing on children practices can help prevent childhood di-
arrhea incidences [17]. This is because proper breast feeding and initiation of
complementary feeding on 6th months provide protective factors that could help
reduce various infections including diarrhea. This also strengthens the immunity
of children which indirectly reduces diarrhea causative organism(s) accidentally
introduced into supplementary foods during feeding practices and due to unhy-
gienic procedures in the preparation of feeds, materials and types of water used
[17]. Finally, although water, sanitation and hygiene related interventions have
been found to successfully reduce the global burden of diarrhea, one main cause
of diarrhea mortality, rotavirus is not prevented using these interventions [48].
Rotavirus is associated with approximately one third of diarrhea deaths and can
only be adequately prevented through vaccination [48]. Therefore, according to
[48], vaccination has been reported as the strongest protection against vac-
cine-preventable causes of diarrhea among children under 5 years globally.

4. Conclusions
Diarrheal disease among under-five children is significantly high and has been
identified as the major cause of mortality and morbidity worldwide [7]. The re-
view established that, childhood diarrhea is a global burden and is significantly
higher in low and middle income countries like Kenya which are highly asso-

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W. M. Manetu et al.

ciated with lack or inadequate clean water for drinking as well as poor sanitation
facilities and hygiene practices [4]. Additionally, the review found that, the sig-
nificant independent variables associated with diarrheal diseases among children
under the age of 5 years are educational status of mother/caretakers, occupation-
al status of the mother, housing floor material, source and quality of domestic
water, gender and age of the child, methods of hand washing, refuse disposal
methods amongst others [31] [32] [33] [34]. These findings have been found to
have important policy implications for childhood diarrhoeal disease intervention
programs. Therefore, interventions such as proper handwashing techniques at
all appropriate times, water treatment and practicing safe storage, improving
nutrition and better child care are highly evidenced to reduce childhood diarr-
hea and especially in African countries [39]-[49]. Also, the review established
health educations about personal hygiene as well as proper disposal of wastes in-
cluding excreta in integration with the existing national health extension pro-
gram like child immunization as an intervention that can reduce mortality and
morbidity cases of childhood diarrhea [31] [32]. Unfortunately, the costs related
to achieving better hygiene and sanitation facilities still remain high [24] [49],
hence only few people can afford and therefore many individuals rely on the
available facilities irrespective of their biological, chemical and physical state.
Consequently, this has been the reason why diarrhea disease has taken over oth-
er diseases to being one of the leading causes of deaths and illness among child-
ren under 5 years globally.
However, the analysis of childhood diarrhea and associated risk factors has
become a concern all in both developed and developing countries. For instance,
a number of studies in developing countries [16] [19] [20] [50] [51] have been
carried out to study diarrhea disease among children under 5 years. However,
most of them so far have focused exclusively on the risk factors that cause the
disease and how the disease can be prevented. Although these studies are very
crucial in understanding the burden of childhood diarrhea disease and its effects
on the affected individual, they fail to explain the spatial-temporal relationship
of the identified factors as well as the spatial relationship between the factors and
diarrhea incidence. Further, such studies also fail to delineate territories of high
and low risk of the childhood diarrhea disease which is usually very useful to
health care officials. Disease level differ substantially from one area to another
and it is therefore essential to characterize these areal variations and delineate
areas of hot spots and cold spots to allow appropriate public health policy deci-
sions [52]. According to [53] [54], improvements in Geographical Information
Systems (GIS) technology offers numerous opportunities for epidemiologists to
study the spatial distribution of diseases and also understand the relationships
between socio-economic, behavioral and environmental factors and the occur-
rence of diseases. For instance, GIS techniques have been employed in the inves-
tigation and monitoring of vector-borne diseases [55] [56], health education [57]
waterborne diseases [58] [59], as well as in environmental health [60] [61].
Geospatial Information System is a software that links geographic information

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 W. M. Manetu et al.

with descriptive information [62]. It provides, efficient, fast and easier to use
functions which enable integration of various data sources their harmonization
and combined analysis towards achieving a particular objective [62]. In addition,
GIS helps in the initial identification of the main cause, visualization and analyze
the spatial relationship between various factors explaining a certain dependent
phenomenon.

Acknowledgements
Many thanks to my lecturer Charles W. Recha for his advice and improvements
he made on this paper. My utmost gratitude to Stephen M’masi. His useful com-
ments are highly appreciated.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

References
[1] Mohammed, S., Tilahun, M. and Tamiru, D. (2013) Morbidity and Associated Fac-
tors of Diarrheal Diseases among Under-Five Children in Arba-Minch District,
Southern Ethiopia, 2012. Science Journal of Public Health, 1, 102-106.
https://doi.org/10.11648/j.sjph.20130102.19
[2] Ahs, J.W., Tao, W., Löfgren, J. and Forsberg, B.C. (2010) Diarrheal Diseases in Low-
and Middle-Income Countries: Incidence, Prevention and Management. The Open
Infectious Diseases Journal, 4, 113-124.
https://doi.org/10.2174/1874279301004010113
[3] Parashar, U.D., Gibson, C.J., Bresee, J.S. and Glass, R.I. (2006) Rotavirus and Severe
Childhood Diarrhea. Emerging Infectious Diseases, 12, 304-306.
https://doi.org/10.3201/eid1202.050006
[4] Boschi-Pinto, C., Velebit, L. and Shibuya, K. (2008) Estimating Child Mortality Due
to Diarrhoea in Developing Countries. Bulletin of the World Health Organization,
86, 710-717. https://doi.org/10.2471/BLT.07.050054
[5] Keusch, G.T., et al. (2006) Chapter 19. Diarrheal Diseases. In: Disease Control
Priorities in Developing Countries, 2nd Edition, Oxford University Press, Oxford,
371-388. https://doi.org/10.1596/978-0-8213-6179-5/Chpt-19
[6] DuPont, H.L. (2008) Diarrheal Diseases (Acute). Cambridge World History Human
Disease, 676-680.
[7] WHO and UNICEF (2009) Diarrhoea: Why Children Are Still Dying and What Can
Be Done.
[8] Soiza, R.L., Donaldson, A.I.C. and Myint, P.K. (2018) Vaccine against Arterioscle-
rosis: An Update. Therapeutic Advances in Vaccines, 9, 259-261.
https://doi.org/10.1177/2042098618769568
[9] Lakshminarayanan, S. and Jayalakshmy, R. (2015) Diarrheal Diseases among
Children in India: Current Scenario and Future Perspectives. Journal of Natural
Science, Biology, and Medicine, 6, 24-28. https://doi.org/10.4103/0976-9668.149073
[10] Reiner, R.C., et al. (2018) Variation in Childhood Diarrheal Morbidity and Mortali-
ty in Africa, 2000-2015. The New England Journal of Medicine, 379, 1128-1138.

DOI: 10.4236/ojepi.2021.113018 217 Open Journal of Epidemiology

W. M. Manetu et al.

[11] Samwel, M., Eddison, M., Faith, N., Richard, S., Elizabeth, M. and Douglas, N.
(2014) Determinants of Diarrhea among Young Children under the Age of Five in
Kenya, Evidence from KDHS 2008-09. Etude la Popul Africaine, 28, 1046-1056.
https://doi.org/10.11564/28-0-556
[12] KDHS (2014) KDHS. Social Welfare in Africa, 1-358.
[13] Naghavi, M., et al. (2017) Global, Regional, and National Age-Sex Specific Mortality
for 264 Causes of Death, 1980-2016: A Systematic Analysis for the Global Burden of
Disease Study 2016. The Lancet, 390, 1151-1210.
[14] Troeger, C., et al. (2017) Estimates of Global, Regional, and National Morbidity,
Mortality, and Aetiologies of Diarrhoeal Diseases: A Systematic Analysis for the
Global Burden of Disease Study 2015. The Lancet Infectious Diseases, 17, 909-948.
[15] MOH (2014) Kenya Environmental Sanitation and Hygeine Policy (Draft).
[16] Kabew, G., Mengistie, B., Mulat, W. and Sahilu, G. (2019) Risk Factors for Acute
Childhood Diarrhea: A Cross-Sectional Study Comparing Refugee Camps and Host
Communities in Gambella Region, Ethiopia. Travel Medicine and Infectious Dis-
ease, 31, Article ID: 101385. https://doi.org/10.1016/j.tmaid.2019.02.003
[17] Asfaha, K.F., et al. (2018) Determinants of Childhood Diarrhea in Medebay Zana
District, Northwest Tigray, Ethiopia: A Community Based Unmatched Case-Control
Study. BMC Pediatrics, 18, 120. https://doi.org/10.1186/s12887-018-1098-7
[18] Ayele, A., Awoke, W. and Tarekegn, M. (2014) Crossectional Survey; Assessment of
Diarrheal Disease. Global Journal of Medical Research F: Diseases, 14.
[19] Children, U. (2018) Factors Related to the Occurrence of Diarrheal Disease in Un-
der-Five Children of IDP’s in Bosaso, Puntland-Somalia Factors Related to the Oc-
currence of Diarrheal Disease in 2016.
[20] Fartun Osman, M.S., Abdirisaq, H. and Abdirahman, M. (2017) Factors Influencing
the Occurrence of Diarrhoea among Children under the Age of Five Admitted to
Benadir Hospital Mogadishu-Somalia. Vol. 1.
[21] Heidegger, C.P., Graf, S., Perneger, T., Genton, L., Oshima, T. and Pichard, C.
(2016) The Burden of Diarrhea in the Intensive Care unit (ICU-BD): A Survey and
Observational Study of the Caregivers’ Opinions and Workload. International
Journal of Nursing Studies, 59, 163-168.
https://doi.org/10.1016/j.ijnurstu.2016.04.005
[22] Ngabo, F., et al. (2016) The Economic Burden Attributable to a Child’s Inpatient
Admission for Diarrheal Disease in Rwanda. PLoS ONE, 11, e0149805.
https://doi.org/10.1371/journal.pone.0149805
[23] Osano, B.O., Wang’ombe, J.K., Kamenwa, R.W. and Wamalwa, D. (2011) Cost
Analysis of Care for Children Admitted to Kenyatta National Hospital with Rotavi-
rus Gastroenteritis. Vaccine, 29, 4019-4024.
https://doi.org/10.1016/j.vaccine.2011.03.053
[24] Aikins, M., Armah, G., Akazili, J. and Hodgson, A. (2010) Hospital Health Care
Cost of Diarrheal Disease in Northern Ghana. The Journal of Infectious Diseases,
202, S126-S130. https://doi.org/10.1086/653573
[25] Rheingans, R., et al. (2012) Determinants of Household Costs Associated with Child-
hood Diarrhea in 3 South Asian Settings. Clinical Infectious Diseases, 55, S327-S335.
https://doi.org/10.1093/cid/cis764
[26] Khalil, A.-M., Troeger, C., Rao, P., Forouzanfar, M., Columbara, D., Misra, K. and
Mokdad, A. (2016) Assessing the Nonfatal Burden of Childhood Diarrhea Including
Malnutrition, Physical Growth, and Cognitive Development. Open Forum Infec-

DOI: 10.4236/ojepi.2021.113018 218 Open Journal of Epidemiology

 W. M. Manetu et al.

tious Diseases, 3, 1220. https://doi.org/10.1093/ofid/ofw172.923

[27] Ochoa, T.J., Salazar-Lindo, E. and Cleary, T.G. (2004) Management of Children
with Infection-Associated Persistent Diarrhea. Seminars in Pediatric Infectious
Diseases, 15, 229-236. https://doi.org/10.1053/j.spid.2004.07.003
[28] Steinhoffa, M.C. (2018) Interactions of Diarrhea, Pneumonia, and Malnutrition in
Childhood: Recent Evidence from Developing Countries. Physiology & Behavior,
176, 139-148.
[29] Kassebaum, N.J., et al. (2019) Diseases, Injuries, and Risk Factors in Child and
Adolescent Health, 1990 to 2017: Findings from the Global Burden of Diseases, In-
juries, and Risk Factors 2017 Study. JAMA Pediatrics, 173, e190337.
[30] Afzal, A. (2017) Association of Socio-Demographic Factors with Dietary Practices
of Mothers in Under-Five Children with Diarrhea. International Journal of Bio-
technology and Bioengineering, 3, 236-241.
https://doi.org/10.25141/2475-3432-2017-6.0230
[31] Habtu, M., et al. (2017) Factors Contributing to Diarrheal Diseases among Children
Less than Five Years in Nyarugenge District, Rwanda. Journal of Tropical Diseases,
5, 3.
[32] Asfaha, K.F., Tesfamichael, F.A., Fisseha, G.K., Misgina, K.H., Weldu, M.G., Wele-
haweria, N.B. and Gebregiorgis, Y.S. (2018) Determinants of Childhood Diarrhea in
Medebay Zana District, Northwest Tigray, Ethiopia: A Community Based Un-
matched Case-Control Study. BMC Pediatrics, 18, 1-9.
https://doi.org/10.1186/s12887-018-1098-7
[33] Connell, B.J.O., Quinn, M.A. and Scheuerman, P. (2017) Risk Factors of Diarrheal
Disease among Children in the East African Countries of Burundi, Rwanda and
Tanzania. Global Journal of Medicine and Public Health, 6, 1.
[34] Mamboleo, D.M., Njoroge, S.M. and Okaru, F.N. (2016) The Prevalence of Diarr-
heal Diseases in Childcare Institutions, Uasin Gishu The Prevalence of Diarrheal
Diseases in Childcare Institutions, Uasin Gishu County, Kenya.
[35] Danquah, L., Curtis, V. and Aunger, R. (2007) What Do We Know about Hand
Washing Practices? Hygiene Centre for Unilever PLC.
[36] Getu, D., Gedefaw, M. and Abebe, N. (2014) Childhood Diarrheal Diseases and As-
sociated Factors in the Rural Community of Dejen District, Northwest Ethiopia,
2014. American Scientific Research Journal for Engineering, Technology, and
Sciences, 5, 1-13.
[37] Id, S.Y., Hudani, A., Udenigwe, O. and Shah, V. (2018) Improving Water, Sanita-
tion and Hygiene Practices, and Housing Quality to Prevent Diarrhea among Un-
der-Five Children in Nigeria. Tropical Medicine and Infectious Disease, 3, 41.
[38] Hung, B.V. (2006) The Most Common Causes of and Risk Factors for Diarrhea
among Children Less than Five Years of Age Admitted to Dong Anh Hospital, Ha-
noi, Northern Vietnam.
[39] Melese, B., Paulos, W., Astawesegn, F.H. and Gelgelu, T.B. (2019) Prevalence of Di-
arrheal Diseases and Associated Factors among Under-Five Children in Dale Dis-
trict, Sidama Zone, Southern Ethiopia: A Cross-Sectional Study. BMC Public
Health, 19, Article No. 1235. https://doi.org/10.1186/s12889-019-7579-2
[40] Esrey, S.A., Feachem, R.G. and Hughes, J.M. (1985) Interventions for the Control of
Diarrhoeal Diseases among Young Children: Improving Water Supplies and Excre-
ta Disposal Facilities. Bulletin of the World Health Organization, 63, 757-772.
[41] Fewtrell, L., Kaufmann, R.B., Kay, D., Enanoria, W., Haller, L. and Colford, J.M.
(2005) Water, Sanitation, and Hygiene Interventions to Reduce Diarrhoea in Less

DOI: 10.4236/ojepi.2021.113018 219 Open Journal of Epidemiology

W. M. Manetu et al.

Developed Countries: A Systematic Review and Meta-Analysis. The Lancet Infec-

tious Diseases, 5, 42-52. https://doi.org/10.1016/S1473-3099(04)01253-8
[42] Ri, E., Je, E., Arikpo, D., Mm, M. and Ja, C. (2015) Hand Washing Promotion for
Preventing Diarrhoea. Cochrane Database of Systematic Reviews, No. 9, CD004265.
[43] Luby, S.P., et al. (2006) Combining Drinking Water Treatment and Hand Washing
for Diarrhoea Prevention, a Cluster Randomised Controlled Trial. Tropical Medi-
cine & International Health, 11, 479-489.
https://doi.org/10.1111/j.1365-3156.2006.01592.x
[44] Garrett, V., et al. (2008) Diarrhoea Prevention in a High-Risk Rural Kenyan Popu-
lation through Point-of-Use Chlorination, Safe Water Storage, Sanitation, and
Rainwater Harvesting. Epidemiology & Infection, 136, 1463-1471.
https://doi.org/10.1017/S095026880700026X
[45] Arnold, B.F. and Colford, J.M. (2007) Treating Water with Chlorine at Point-of-Use
to Improve Water Quality and Reduce Child Diarrhea in Developing Countries: A
Systematic Review and Meta-Analysis. American Journal of Tropical Medicine and
Hygiene, 76, 354-364. https://doi.org/10.4269/ajtmh.2007.76.354
[46] Lule, J.R., et al. (2005) Effect of Home-Based Water Chlorination and Safe Storage
on Diarrhea among Persons with Human Immunodeficiency Virus in Uganda.
American Journal of Tropical Medicine and Hygiene, 73, 926-933.
https://doi.org/10.4269/ajtmh.2005.73.926
[47] Quick, R.E., et al. (2002) Diarrhea Prevention through Household-Level Water
Disinfection and Safe Storage in Zambia. American Journal of Tropical Medicine
and Hygiene, 66, 584-589. https://doi.org/10.4269/ajtmh.2002.66.584
[48] Lamberti, L.M., Ashraf, S., Walker, C.L.F. and Black, R.E. (2016) A Systematic Re-
view of the Effect of Rotavirus Vaccination on Diarrhea Outcomes among Children
Younger than 5 Years. The Pediatric Infectious Disease Journal, 35, 992-998.
https://doi.org/10.1097/INF.0000000000001232
[49] Bin Halim, F. and Haider, M.Z. (2017) Prevalence and Economic Costs of Diarrheal
Illness among Adult Slum Dwellers in Khulna City, Bangladesh. Journal of Health
and Social Sciences, 120, 83-98.
[50] Musoke, D., Ndejjo, R., Halage, A.A., Kasasa, S., Ssempebwa, J.C. and Carpenter,
D.O. (2018) Drinking Water Supply, Sanitation, and Hygiene Promotion Interven-
tions in Two Slum Communities in Central Uganda. Journal of Environmental and
Public Health, 2018, Article ID: 3710120. https://doi.org/10.1155/2018/3710120
[51] Njeru, P.M., Kariri, J.M., Murigi, M.W., Waweru, H.M. and Muriithi, F.M. (2017)
Management of Diarrheal Diseases among Children under Five Years: A Case Study
of Mothers at Kakamega County, Kenya. International Journal of Community
Medicine and Public Health, 4, 2762.
https://doi.org/10.18203/2394-6040.ijcmph20173319
[52] Musa, G.J., et al. (2013) Use of GIS Mapping as a Public Health Tool—From Chole-
ra to Cancer. Health Services Insights, 6, 111-116.
https://doi.org/10.4137/HSI.S10471
[53] Croner, C.M. (2003) Public Health, GIS, and the Internet. Annual Review of Public
Health, 24, 57-82. https://doi.org/10.1146/annurev.publhealth.24.012902.140835
[54] ESRI (2005) Approaches to GIS Programs In Health Education.
[55] Pathirana, S., Kawabata, M. and Goonatilake, R. (2009) Study of Potential Risk of
Dengue Disease Outbreak in Sri Lanka Using GIS and Statistical Modelling. Journal
of Rural and Tropical Public Health, 8, 8-17.

DOI: 10.4236/ojepi.2021.113018 220 Open Journal of Epidemiology

 W. M. Manetu et al.

[56] Kala, A.K., Tiwari, C., Mikler, A.R. and Atkinson, S.F. (2017) A Comparison of
Least Squares Regression and Geographically Weighted Regression Modeling of
West Nile Virus Risk Based on Environmental Parameters. PeerJ, 5, e3070.
https://doi.org/10.7287/peerj.preprints.2673
[57] Shanmugam, G. (2018) WASH (Water, Sanitation and Hygiene). International Journal
of Trend in Scientific WASH (Water, Sanitation and Hygiene), 2, 577.
[58] Osei, F.B. and Duker, A.A. (2008) Spatial Dependency of V. cholera Prevalence on
Open Space Refuse Dumps in Kumasi, Ghana: A Spatial Statistical Modelling. In-
ternational Journal of Health Geographics, 7, 62.
https://doi.org/10.1186/1476-072X-7-62
[59] Nkeki, F.N. and Osirike, A.B. (2013) GIS-Based Local Spatial Statistical Model of
Cholera Occurrence: Using Geographically Weighted Regression. Journal of Geo-
graphic Information System, 5, 531-542. https://doi.org/10.4236/jgis.2013.56050
[60] Maantay, J. (2002) Mapping Environmental Injustices: Pitfalls and Potential of
Geographic Information Systems in Assessing Environmental Health and Equity.
Environmental Health Perspectives, 110, 161-171.
https://doi.org/10.1289/ehp.02110s2161
[61] Chakraborty, J., Maantay, J.A. and Brender, J.D. (2011) Disproportionate Proximity
to Environmental Health Hazards: Methods, Models, and Measurement. American
Journal of Public Health, 101, S27-S36. https://doi.org/10.2105/AJPH.2010.300109
[62] ESRI (2012) What Is GIS?

DOI: 10.4236/ojepi.2021.113018 221 Open Journal of Epidemiology