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Overcoming barriers in evaluating outbreaks of diarrheal disease in resource poor settings: assessment of recurrent outbreaks in Chobe District, Botswana

KA Alexander12* and JK Blackburn34

Author affiliations

1 Department of Fish and Wildlife Conservation, Virginia Tech, 132 Cheatham Hall, Blacksburg, Virginia 24061, USA

2 CARACAL (Center for Conservation of African Resources: Animals, Communities and Land use), Kasane, Botswana

3 Department of Geography, Spatial Epidemiology & Ecology Research Laboratory, University of Florida, Gainesville, Florida, USA

4 Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA

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Citation and License

BMC Public Health 2013, 13:775  doi:10.1186/1471-2458-13-775

Published: 26 August 2013



Diarrheal illness remains a leading cause of global morbidity and mortality, with the majority of deaths occurring in children <5 years of age. Lack of resources often prohibits the evaluation of outbreak characteristics and limits progress in managing this important disease syndrome, particularly in Africa. Relying only on existing medical staff and hospital resources, we assess the use of a questionnaire survey tool to identify baseline outbreak characteristics during recurrent diarrheal outbreaks in Chobe, Botswana.


Using historical surveillance data (2006–2009), the temporal pattern of recurrent diarrheal outbreaks was evaluated among patients <5 years of age presenting to health facilities in Chobe District. Using a questionnaire survey tool, medical staff from selected health facilities assessed patients (all ages) presenting with diarrheal disease during two diarrheal outbreaks (2011–2012). Cluster analysis and classification and regression trees (CART) were used to evaluate patient attributes by outbreak.


We identified a bimodal, annual pattern of acute diarrhea in children <5 years of age across years (Wilcox test, W = 456.5, p = 0.052). Historical outbreak periods appeared to coincide with major hydrological phenomena (rainfall/flood recession). Across health facilities, a significant percent of patients in the prospective study were in the ≥5 age class (44%, n = 515 and 35%, n = 333 in the dry and wet season outbreaks, respectively). Cluster analysis of questionnaire data identified two main branches associated with patient age (<5 and ≥5 years of age). Patients did not cluster by outbreak or village. CART examination identified sex and hospitalization as being most predictive of patients <5 years and household diarrhea in patients ≥5 years. Water shortages and water quality deficiencies were identified in both outbreaks.


Diarrhea is a persistent, seasonally occurring disease in Chobe District, Botswana. Lack of variation in outbreak variables suggests the possibility of environmental drivers influencing outbreak dynamics and the potential importance of human-environmental linkages in this region. Public health strategy should be directed at securing improved water service and correcting water quality deficiencies. Public health education should include increased emphasis on sanitation practices when providing care to household members with diarrhea. While global diarrheal disease surveillance is directed at the under-5 age group, this may not be appropriate in areas of high HIV prevalence such as that found in our study area where a large immune-compromised population may warrant increased surveillance across age groups. The approach used in this study provided the first detailed characterization of diarrheal disease outbreaks in the area, an important starting point for immediate intervention and development of working hypotheses for future disease investigations. While data derived from this approach are necessarily limited, they identify critical information on outbreak characteristics in resource poor settings where data gaps continue and disease incidence is high.

Diarrhea; Outbreak investigation; Breastfeeding; Water shortage; Water quality; Surface water; Climate; Under 5 years of age; Cluster analysis; Public health; Poverty; Resource poor; Africa; Botswana