Global Enteric Multicenter Study (GEMS)

GEMS, funded by the Bill & Melinda Gates Foundation, was a prospective, multi-center, case-control study of acute diarrhea in children 0-59 months of age. The study was conducted at seven sites in Africa and Asia, representing developing countries with moderate or high infant mortality rates; rural or urban settings; and high or low prevalence of human immunodeficiency virus (HIV) and malaria. Each site recruited up to 880 children with severe diarrhea from hospitals or ambulatory facilities and 880 matched community controls in 3 age strata: 0-11 months, 12-23 months and 24-59 months.

Participants provided clinical and epidemiological data and a fecal sample for identification and antigenic characterization of various bacterial, viral, and protozoal enteropathogens. Population-based, age-specific incidences and pathogen-specific, severe diarrhea-associated attributable disease burden was calculated using site-specific census and health care utilization surveys. A "pathogenicity index" was derived by comparing isolation frequencies of each pathogen for cases and controls. Deaths and sequelae attributed to pathogens were determined acutely and at 60-day follow-up visits. In addition to the health burden, the public and private financial costs, both direct and indirect, incurred by an episode of severe diarrhea in a child 0-59 months of age was assessed.

The research consortium involved in the project includes most of the global players in vaccine development and the diagnosis and treatment of diarrheal diseases. Institutions and organizations participating in the project included: Centro de Investigaçao em Saude da Manhiça Manhiça, Mozambique; Medical Research Council, Basse, The Gambia; CDC/Kenya Medical Research Institute (KMRI) Research Station, Kisumu, Kenya; Centre pour le Développement des Vaccins du Mali (CVD-Mali), Bamako, Mali; National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India; International Center for Diarrheal Disease Research (ICDDR,B), Mirzapur, Bangladesh; Aga Khan University, Pakistan; Perry Point Veterans Administration Medical Center in Maryland; US Centers for Disease Control and Prevention; University of Chile; University of Virginia School of Medicine; International Vaccine Institute, Seoul, Korea; Institut Pasteur, Paris, France; World Health Organization; Center for International Health at the University of Bergen and the Institute of Public Health in Norway; University of Goteborg, Sweden; Rollins School of Public Health at Emory University, Atlanta, Georgia, and the Johns Hopkins University Bloomberg School of Public Health in Maryland.

The primary goal of GEMS was to conduct a multi-center study to quantify the burden and identify the microbiologic etiology of severe diarrheal disease among children 0-59 months of age living in developing countries in Africa and Asia. The study was conducted at seven experienced and well-characterized sites. GEMS used common research protocol to address limitations of previous studies and satisfy contemporary needs for information.

The ultimate goal was to collect data to guide development and implementation of enteric vaccines and other public health interventions to diminish morbidity and mortality from diarrheal diseases. The following tasks were designed to achieve this overriding goal:

• Quantify burden and adverse clinical consequences of severe diarrheal disease and identify the microbiologic etiology by age stratum (0-11 months, 12-23 months, 24-59 months) and clinical syndrome at each site, in each region, and across all sites.
• Characterize the phenotype and/or genotype distribution of major enteric pathogens.
• Prepare an evidence-based assessment (based on disease burden, economic analysis, and public perception) of public and private costs of diarrheal disease caused by major indicated pathogens, by country and by region, among children 0-59 months of age, and the public demand for an intervention.
• Archive and store the well-characterized clinical specimens and isolated etiologic agents so that they can be accessed in the future for research and technology development.

GEMS was led by the CVD with considerable collaboration with the following:

• Cooperative Studies Program Coordinating Center (CSPCC), VA Medical Center, Perry Point, Maryland

• Centers for Disease Control and Prevention (CDC), National Center for Immunization and Respiratory Diseases (NCIRD), formerly Foodborne and Diarrheal Disease Branch, Atlanta, Georgia

• International Vaccine Institute, Seoul, Korea

• CVD-Chile and University of Chile, Santiago, Chile

• University of Virginia School of Medicine, Charlottesville, VA, USA

• The Department of Medical Microbiology & Immunology (DMMI), Göteborg University, Goteborg, Sweden

The GEMS Repository consists of data, and stool and bacterial samples, from every child studied in GEMS-1 and GEMS-1A. Additionally, isolated nucleic acids from all stool samples are in the GEMS Repository.

Data is available at http://clinepidb.org.

The following specimens are available upon request:

• Bacterial isolates
• Stool specimens
• Nucleic acid from stool specimens

To request specimens, email a brief description of your request to GEMSRequest@som.umaryland.edu.

Click on the publication name to view the article.

2017

Schilling KA, Omore R, Derado G, Ayers T, Ochieng JB, Farag TH, Nasrin D, Panchalingam S, Nataro JP, Kotloff KL, Levine MM, Oundo J, Parsons MB, Bopp C, Laserson K, Stauber CE, Rothenberg R, Breiman RF, O'Reilly CE, Mintz ED. (2017). Factors associated with the duration of moderate-to-severe diarrhea among children in rural western Kenya enrolled in the Global Enteric Multicenter Study, 2008-2012. Am J Trop Med Hyg. 2017;97(1), 248-258. doi: 10.4269/ajtmh.16-0898

2016

Baker KK, O'Reilly CE, Levine MM, Kotloff KL, Nataro JP, Ayers TL, Farag TH, Nasrin D, Blackwelder WC, Wu Y, Alonso PL, Breiman RF, Omore R, Faruque AS, Das SK, Ahmed S, Saha D, Sow SO, Sur D, Zaidi AK, Quadri F, Mintz ED. Sanitation and hygiene-specific risk factors for moderate-to-severe diarrhea in young children in the Global Enteric Multicenter Study, 2007-2011: Case-control study. PLoS Med. 2016 May;13(5). doi: 10.1371/journal.pmed.1002010

Hazen TH, Donnenberg MS, Panchalingam S, Antonio M, Hossain A, Mandomando I, Ochieng JB, Ramamurthy T, Tamboura B, Qureshi S, Quadri F, Zaidi A, Kotloff KL, Levine MM, Barry EM, Kaper JB, Rasko DA, Nataro JP. (2016). Genomic diversity of EPEC associated with clinical presentations of differing severity. Nat Microbiol. 2016 Jan;1(15014). doi: 10.1038/nmicrobiol.2015.14

Ingle DJ, Tauschek M, Edwards DJ, Hocking DM, Pickard DJ, Azzopardi KI, Amarasena T, Bennett-Wood V, Pearson JS, Tamboura B, Antonio M, Ochieng JB, Oundo J, Mandomando I, Qureshi S, Ramamurthy T, Hossain A, Kotloff KL, Nataro JP, Dougan G, Levine MM, Robins-Browne RM, Holt KE. Evolution of atypical enteropathogenic E. coli by repeated acquisition of LEE pathogenicity island variants. Nat Microbiol. 2016 Jan;1(15010). doi: 10.1038/nmicrobiol.2015.10

Liu J, Platts-Mills JA, Juma J, Kabir F, Nkeze J, Okoi C, Operario DJ, Uddin J, Ahmed S, Alonso PL, Antonio M, Becker SM, Blackwelder WC, Breiman RF, Faruque AS, Fields B, Gratz J, Haque R, Hossain A, Hossain MJ, Jarju S, Qamar F, Iqbal NT, Kwambana B, Mandomando I, McMurry TL, Ochieng C, Ochieng JB, Ochieng M, Onyango C, Panchalingam S, Kalam A, Aziz F, Qureshi S, Ramamurthy T, Roberts JH, Saha D, Sow SO, Stroup SE, Sur D, Tamboura B, Taniuchi M, Tennant SM, Toema D, Wu Y, Zaidi A, Nataro JP, Kotloff KL, Levine MM, Houpt ER. Use of quantitative molecular diagnostic methods to identify causes of diarrhoea in children: a reanalysis of the GEMS case-control study. Lancet. 2016 Sept;388(10051), 1291-1301. doi: 10.1016/s0140-6736(16)31529-x

Omore R, Tate J, O'Reilly CE, Ayers T, Williamson J, Moke F, Schilling KA, Awuor AO, Jaron P, Ochieng JB, Oundo J, Parashar UD, Parsons MB, Bopp CC, Nasrin D, Farag TH, Kotloff KL, Nataro JP, Panchalingam S, Levine MM, Laserson KF, Nuorti JP, Mintz ED, Breiman RF. (2016). Epidemiology, seasonality and factors associated with rotavirus infection among children with moderate-to-severe diarrhea in rural western Kenya, 2008-2012: The Global Enteric Multicenter Study (GEMS). PLoS One. 2016;11(8). doi: 10.1371/journal.pone.0160060

Qamar FN, Nisar MI, Quadri F, Shakoor S, Sow SO, Nasrin D, Blackwelder WC, Wu Y, Farag T, Panchalingham S, Sur D, Qureshi S, Faruque AS8, Saha D9, Alonso PL10, Breiman RF11, Bassat Q12, Tamboura B13, Ramamurthy T7, Kanungo S7, Ahmed S9, Hossain A9, Das SK9, Antonio M14, Hossain MJ14, Mandomando I, Tennant SM, Kotloff KL, Levine MM, Zaidi AK. Aeromonas-associated diarrhea in children under 5 years: The GEMS experience. Am J Trop Med Hyg. 2016;95(4), 774-780. doi: 10.4269/ajtmh.16-0321

Sow SO, Muhsen K, Nasrin D, Blackwelder WC, Wu Y, Farag TH, Panchalingam S, Sur D, Zaidi AK, Faruque AS, Saha D, Adegbola R, Alonso PL, Breiman RF, Bassat Q, Tamboura B, Sanogo D, Onwuchekwa U, Manna B, Ramamurthy T, Kanungo S, Ahmed S, Qureshi S, Quadri F, Hossain A, Das SK, Antonio M, Hossain MJ, Mandomando I, Nhampossa T, Acácio S, Omore R, Oundo JO, Ochieng JB, Mintz ED, O'Reilly CE, Berkeley LY, Livio S, Tennant SM, Sommerfelt H, Nataro JP, Ziv-Baran T, Robins-Browne RM, Mishcherkin V, Zhang J, Liu J, Houpt ER, Kotloff KL, Levine MM. The burden of Cryptosporidium diarrheal disease among children < 24 months of age in moderate/high mortality regions of sub-Saharan Africa and South Asia, utilizing data from the Global Enteric Multicenter Study (GEMS). PLoS Negl Trop Dis. 2016 May;10(5). doi: 10.1371/journal.pntd.0004729

2015

Lindsay B, Saha D, Sanogo D, Das SK, Farag TH, Nasrin D, Li S, Panchalingam S, Levine MM, Kotloff K, Nataro JP, Magder L, Hungerford L, Oundo J, Hossain MA, Adeyemi M, Stine OC, Faruque AS. Association between Shigella infection and diarrhea varies based on location and age of children. Am J Trop Med Hyg. 2015 Nov;93(5):918–924. doi: 10.4269/ajtmh.14-0319

Donnenberg MS, Hazen TH, Farag TH, Panchalingam S, Antonio M, Hossain A, Mandomando I, Ochieng JB, Ramamurthy T, Tamboura B, Zaidi A, Levine MM, Kotloff K, Rasko DA, Nataro JP. Bacterial factors associated with lethal outcome of enteropathogenic Escherichia coli infection: Genomic case-control studies. PLoS Negl Trop Dis. 2015 May 15;9(5):e0003791. doi: 10.1371/journal.pntd.0003791.

Nhampossa T, Mandomando I, Acacio S, Quintó L, Vubil D, Ruiz J, Nhalungo D, Sacoor C, Nhabanga A, Nhacolo A, Aide P, Machevo S, Sigaúque B, Nhama A, Kotloff K, Farag T, Nasrin D, Bassat Q, Macete E, Levine MM, Alonso P. Diarrheal disease in rural Mozambique: Burden, risk factors and etiology of diarrheal disease among children Aged 0-59 months seeking care at health facilities. PLoS One. 2015 May 14. doi: 10.1371/journal.pone.0119824.

Lindsay B, Oundo J, Hossain MA, Antonio M, Tamboura B, Walker AW, Paulson JN, Parkhill J, Omore R, Faruque AS, Das SK, Ikumapayi UN, Adeyemi M, Sanogo D, Saha D, Sow S, Farag TH, Nasrin D, Li S, Panchalingam S, Levine MM, Kotloff K, Magder LS, Hungerford L, Sommerfelt H, Pop M, Nataro JP, Stine OC. Microbiota that affect risk for shigellosis in children in low-income countries. Emerg Infect Dis. 2015 Feb;21(2):242-50. doi: 10.3201/eid2101.140795.

2014

Livio S, Strockbine NA, Panchalingam S, Tennant SM, Barry EM, Marohn ME, Antonio M, Hossain A, Mandomando I, Ochieng JB, Oundo JO, Qureshi S, Ramamurthy T, Tamboura B, Adegbola RA, Hossain MJ, Saha D, Sen S, Faruque AS, Alonso PL, Breiman RF, Zaidi AK, Sur D, Sow SO, Berkeley LY, O'Reilly CE, Mintz ED, Biswas K, Cohen D, Farag TH, Nasrin D, Wu Y, Blackwelder WC, Kotloff KL, Nataro JP, Levine MM. Shigella isolates from the Global Enteric Multicenter Study inform vaccine development. Clin Infect Dis. 2014 Oct;59(7):933-41. doi: 10.1093/cid/ciu468

Baker KK, Dil Farzana F, Ferdous F, Ahmed S, Kumar Das S, Faruque AS, Nasrin D, Kotloff KL, Nataro JP, Kolappaswamy K, Levine MM. Association between moderate-to-severe diarrhea in young children in the Global Enteric Multicenter Study (GEMS) and types of handwashing materials used by caretakers in Mirzapur, Bangladesh. Am J Trop Med Hyg. 2014 Jul;91(1):181-9. doi:10.4269/ajtmh.13-0509

Pop M, Walker AW, Paulson J, Lindsay B, Antonio M, Hossain MA, Oundo J, Tamboura B, Mai V, Astrovskaya I, Corrada Bravo H, Rance R, Stares M, Levine MM, Panchalingam S, Kotloff K, Ikumapayi UN, Ebruke C, Adeyemi M, Ahmed D, Ahmed F, Alam MT, Amin R, Siddiqui S, Ochieng JB, Ouma E, Juma J, Mailu E, Omore R, Morris JG, Breiman RF, Saha D, Parkhill J, Nataro JP, Stine OC. Diarrhea in young children from low-income countries leads to large-scale alterations in intestinal microbiota composition. Genome Biol. 2014 Jun 27;15(6):R76. doi: 10.1186/gb-2014-15-6-r76

Kwambana BA, Ikumapayi UN, Sallah N, Dione M, Jarju S, Panchalingham S, Jafali J, Lamin M, Betts M, Adeyemi M, Akinsola A, Bittaye O, Jasseh M, Kotloff KL, Levine MM, Nataro JP, Corrah T, Hossain MJ, Saha D, Antonio M. High genotypic diversity among rotavirus strains infecting Gambian children. Pediatr Infect Dis J. 2014 Jan;33:S69-75. doi: 10.1097/INF.0000000000000087

2013

Lindsay B, Pop M, Antonio M, Walker AW, Volker Mai V, Ahmed D, Oundo J,Tamboura B,Panchalingam S, Levine MM, Kotloff K, Li S, Magder LS, Paulson JN, Liu B,Ikumapay U,Ebruke C,Dione M,Adeyem M, Rance R, Stares MD,Ukhanova M, Barnes B, Lewis I, Ahmed F, Alam MT,Amin R,Siddiqui S,Ochieng JB,Ouma E, Juma J,Mailu E,Omore R,O'Reilly CE,Hannis J,Manalili S,DeLeon J,Yasuda I,Blyn L,Ranken R,Li F,Housley R,Ecker DJ,Hossain MA,Breiman RF,Morris JG,McDaniel TK,  Parkhill J, Saha D,Sampath R,Stine OC, Nataro JP. Survey of culture, goldengate assay, universal biosensor assay, and 16S rRNA gene sequencing as alternative methods of bacterial pathogen detection. J Clin Microbiol. 2013 Oct;51(10):3263-9.

Baker KK, Sow SO, Kotloff KL, Nataro JP, Farag TH, Tamboura B, Doumbia M, Sanogo D, Diarra D, O'Reilly CE, Mintz E, Panchalingam S, Wu Y, Blackwelder WC, Levine MM. Quality of piped and stored water in households with children under five years of age enrolled in the Mali site of the Global Enteric Multi-Center Study (GEMS). Am J Trop Med Hyg. 2013 Aug;89(2):214-22. doi: 10.4269/ajtmh.12-0256

Das SK, Nasrin D, Ahmed S, Wu Y, Ferdous F, Farzana FD, Khan SH, Malek MA, El Arifeen S, Levine MM, Kotloff KL, Faruque AS. Health care-seeking behavior for childhood diarrhea in Mirzapur, rural Bangladesh. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):62-8. doi: 10.4269/ajtmh.13-0107

Farag TH, Kotloff KL, Levine MM, Onwuchekwa U, Van Eijk AM, Doh S, Sow SO. Seeking care for pediatric diarrheal illness from traditional healers in Bamako, Mali. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):21-8. doi: 10.4269/ajtmh.12-0753

Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, Wu Y, Sow SO, Sur D, Breiman RF, Faruque AS, Zaidi AK, Saha D, Alonso PL, Tamboura B, Sanogo D, Onwuchekwa U, Manna B, Ramamurthy T, Kanungo S, Ochieng JB, Omore R, Oundo JO, Hossain A, Das SK, Ahmed S, Qureshi S, Quadri F, Adegbola RA, Antonio M, Hossain MJ, Akinsola A, Mandomando I, Nhampossa T, Acácio S, Biswas K, O'Reilly CE, Mintz ED, Berkeley LY, Muhsen K, Sommerfelt H, Robins-Browne RM, Levine MM. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): A prospective, case-control study. Lancet. 2013 Jul 20;382(9888):209-22.

Manna B, Nasrin D, Kanungo S, Roy S, Ramamurthy T, Kotloff KL, Levine MM, Sur D. Determinants of health care seeking for diarrheal illness in young children in urban slums of Kolkata, India. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):56-61. doi: 10.4269/ajtmh.12-0756

Nasrin D, Wu Y, Blackwelder WC, Farag TH, Saha D, Sow SO, Alonso PL, Breiman RF, Sur D, Faruque AS, Zaidi AK, Biswas K, Van Eijk AM, Walker DG, Levine MM, Kotloff KL. Health care seeking for childhood diarrhea in developing countries: Evidence from seven sites in Africa and Asia. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):3-12. doi: 10.4269/ajtmh.12-0749

Nhampossa T, Mandomando I, Acacio S, Nhalungo D, Sacoor C, Nhacolo A, Macete E, Nhabanga A, Quintó L, Kotloff K, Levine MM, Nasrin D, Farag T, Bassat Q, Alonso P. Health care utilization and attitudes survey in cases of moderate-to-severe diarrhea among children ages 0-59 months in the District of Manhica, southern Mozambique. Am J Trop Med Hyg. 2013 Jul;89(1 Suppl):41-8.

Omore R, O'Reilly CE, Williamson J, Moke F, Were V, Farag TH, van Eijk AM, Kotloff KL, Levine MM, Obor D, Odhiambo F, Vulule J, Laserson KF, Mintz ED, Breiman RF. Health care-seeking behavior during childhood diarrheal illness: Results of health care utilization and attitudes surveys of caretakers in western Kenya, 2007-2010. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):29-40. doi: 10.4269/ajtmh.12-0755

Saha D, Akinsola A, Sharples K, Adeyemi MO, Antonio M, Imran S, Jasseh M, Hossain MJ, Nasrin D, Kotloff KL, Levine MM, Hill PC. Health care utilization and attitudes survey: Understanding diarrheal disease in rural Gambia. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):13-20. doi: 10.4269/ajtmh.12-0751

Quadri F, Nasrin D, Khan A, Bokhari T, Tikmani SS, Nisar MI, Bhatti Z, Kotloff K, Levine MM, Zaidi AK. Health care use patterns for diarrhea in children in low-income periurban communities of Karachi, Pakistan. Am J Trop Med Hyg. 2013 Jul 10;89(1 Suppl):49-55. doi: 10.4269/ajtmh.12-0757

Farag TH, Faruque AS, Wu Y, Das SK, Hossain A, Ahmed S, Ahmed D, Nasrin D, Kotloff KL, Panchilangam S, Nataro JP, Cohen D, Blackwelder WC, Levine MM. Housefly population density correlates with shigellosis among children in Mirzapur, Bangladesh: a time series analysis. PLoS Negl Trop Dis. 2013 Jun 20. doi: 10.1371/journal.pntd.0002280

Lindsay B, Ochieng JB, Ikumapayi UN, Toure A, Ahmed D, Li S, Panchalingam S, Levine MM, Kotloff K, Rasko DA, Morris CR, Juma J, Fields BS, Dione M, Malle D, Becker SM, Houpt ER, Nataro JP, Sommerfelt H, Pop M, Oundo J, Antonio M, Hossain A, Tamboura B, Stine OC. Quantitative PCR for detection of Shigella improves ascertainment of Shigella burden in children with moderate-to-severe diarrhea in low-income countries. J Clin Microbiol. 2013 Jun;51(6):1740-6. doi: 10.1128/JCM.02713-12

2012

Biswas K, Carty C, Horney R, Nasrin D, Farag TH, Kotloff KL, Levine MM. Data management and other logistical challenges for the GEMS: The data coordinating center perspective. Clin Infect Dis. 2012 Dec;55(Suppl 4):S254-61. doi: 10.1093/cid/cis755

Blackwelder WC, Biswas K, Wu Y, Kotloff KL, Farag TH, Nasrin D, Graubard BI, Sommerfelt H, Levine MM. Statistical methods in the Global Enteric Multicenter Study (GEMS). Clin Infect Dis. 2012 Dec;55 Suppl 4:S246-53.

Farag TH, Nasrin D, Wu Y, Muhsen K, Blackwelder WC, Sommerfelt H, Panchalingam S, Nataro JP, Kotloff KL, Levine MM. Some epidemiologic, clinical, microbiologic, and organizational assumptions that influenced the design and performance of the Global Enteric Multicenter Study (GEMS). Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S225-31. doi: 10.1093/cid/cis787

Kotloff KL, Blackwelder WC, Nasrin D, Nataro JP, Farag TH, van Eijk A, Adegbola RA, Alonso PL, Breiman RF, Faruque AS, Saha D, Sow SO, Sur D, Zaidi AK, Biswas K, Panchalingam S, Clemens JD, Cohen D, Glass RI, Mintz ED, Sommerfelt H, Levine MM. The Global Enteric Multicenter Study (GEMS) of diarrheal disease in infants and young children in developing countries: Epidemiologic and clinical methods of the case/control study. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S232-45. doi: 10.1093/cid/cis753

Levine MM, Kotloff KL, Nataro JP, Muhsen K. The Global Enteric Multicenter Study (GEMS): Impetus, rationale, and genesis. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S215-24. doi: 10.1093/cid/cis761

Levine MM, Robins-Browne RM. Factors that explain excretion of enteric pathogens by persons without diarrhea. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S303-11. doi: 10.1093/cid/cis789

Muhsen K, Levine MM. A systematic review and meta-analysis of the association between Giardia lamblia and endemic pediatric diarrhea in developing countries. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S271-93. doi: 10.1093/cid/cis762

Panchalingam S, Antonio M, Hossain A, Mandomando I, Ochieng B, Oundo J, Ramamurthy T, Tamboura B, Zaidi AK, Petri W, Houpt E, Murray P, Prado V, Vidal R, Steele D, Strockbine N, Sansonetti P, Glass RI, Robins-Browne RM, Tauschek M, Svennerholm AM, Berkeley LY, Kotloff K, Levine MM, Nataro JP. Diagnostic microbiologic methods in the GEMS-1 case/control study. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S294-302. doi: 10.1093/cid/cis754

Rheingans R, Kukla M, Adegbola RA, Saha D, Omore R, Breiman RF, Sow SO, Onwuchekwa U, Nasrin D, Farag TH, Kotloff KL, Levine MM. Exploring household economic impacts of childhood diarrheal illnesses in 3 African settings. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S317-26. doi: 10.1093/cid/cis763

Rheingans R, Kukla M, Faruque AS, Sur D, Zaidi AK, Nasrin D, Farag TH, Levine MM, Kotloff KL. Determinants of household costs associated with childhood diarrhea in 3 South Asian settings. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S327-35. doi: 10.1093/cid/cis764

Robins-Browne RM, Levine MM. Laboratory diagnostic challenges in case/control studies of diarrhea in developing countries. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S312-6. doi: 10.1093/cid/cis756

Sommerfelt H, Steinsland H, van der Merwe L, Blackwelder WC, Nasrin D, Farag TH, Kotloff KL, Levine MM, Gjessing HK. Case/control studies with follow-up: Constructing the source population to estimate effects of risk factors on development, disease, and survival. Clin Infect Dis. 2012 Dec 15;55(Suppl 4):S262-70. doi: 10.1093/cid/cis802