Some limitations should be considered. First, because the surveillance system is based in tertiary hospitals, we likely captured a select group of children with severe disease, and the etiologic distribution of diarrheal illnesses may be different in other hospital settings in Bangladesh (eg, in urban and primary care centers). However, at the same time, our surveillance systematically excluded children who died with diarrhea because these children were often admitted after-hours or died quickly after admission. Because of this, suggesting that our approach is not well-suited for studying deaths from rotavirus, and our data likely underestimate the total number of rotavirus-related deaths, as well as case-fatality ratios. Second, year-to-year variation in rotavirus activity is known to occur, and the proportion of diarrhea attributable to rotavirus depends on the prevalence of other enteric pathogens and health-seeking behaviors and thus we may have captured a period of high rotavirus activity. However, rotavirus prevalence estimates were consistent across years and settings. Third, because controls were not included in this evaluation, we may have overestimated the proportion of cases attributable to rotavirus. However, any overestimation is expected to be small, as EIA rarely detects asymptomatic infections, and the attributable fraction of rotavirus detection with EIA has been shown to be >90%.27–29
We thank all the study participants for their time and support. We are also grateful to our implementation partner, surveillance hospital sites and The Institute of Epidemiology, Disease Control and Research (IEDCR) under the Ministry of Health and Family Welfare of Bangladesh Government. Our technical assistance partner: US Centers for Disease Control and Prevention (CDC).
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