Evaluating the Impact of Unadjusted Confounding and Study Design on Estimated Pathogen-attributable Diarrhea Incidence Among Children in the MAL-ED Cohort

40,406 stools samples from 1715 children were included (6625 diarrheal, 33,781 control). Antibiotic use had the greatest confounding impact, and directionality of bias was dependent on pathogen type. Shedding following diarrheal episodes did not substantially or consistently bias estimates. Nested case-control and case-crossover study designs produced similar attributable incidence estimates, and risk-based estimates were lower than odds-based estimates, ranging from 33% (Shigella) to 49% (tEPEC) episodes per 100 child-years fewer than the partially adjusted model.