Quantifying risks and interventions that have affected the burden of diarrhoea among children younger than 5 years: an analysis of the Global Burden of Disease Study 2017
Authors: Christopher E Troeger, Ibrahim A. Khalil, Brigette F. Blacker, Molly H. Biehl, Samuel B. Albertson, Stephanie R M Zimsen, Puja C Rao, Degu Abate, Alireza Ahmadi, Mohamed Lemine Cheikh brahim Ahmed, Chalachew Genet Akal, Fares Alahdab, Noore Alam, Kefyalew Addis Alene, Vahid Alipour, Syed Mohamed Aljunid, Rajaa M Al-Raddadi, Nelson Alvis-Guzman, Saeed Amini, Nahla Hamed Anber, Mina Anjomshoa, Carl Abelardo T. Antonio, Jalal Arabloo, Olatunde Aremu, Hagos Tasew Atalay, Suleman Atique, Euripide F G A Avokpaho, Samah Awad, Ashish Awasthi, Alaa Badawi, Kalpana Balakrishnan, Joseph Adel Mattar Banoub, Aleksandra Barac, Quique Bassat, Neeraj Bedi, Derrick A. Bennett, Krittika Bhattacharyya, Zulfiqar A Bhutta, Ali Bijani, Josip Car, Félix Carvalho, Carlos A Castañeda-Orjuela, Devasahayam J Christopher, Lalit Dandona, Rakhi Dandona, Ahmad Daryani, Feleke Mekonnen Demeke, Aniruddha Deshpande, Shirin Djalalinia, Manisha Dubey, Eleonora Dubljanin, Eyasu Ejeta Duken, Maysaa El Sayed Zaki, Aman Yesuf Endries, Eduarda Fernandes, Florian Fischer, Nancy Fullman, William M. Gardner, Birhanu Geta, Keyghobad Ghadiri, Giuseppe Gorini, Alessandra C Goulart, Yuming Guo, Gessessew Bugssa Hailu, Arvin Haj-Mirzaian, Arya Haj-Mirzaian, Samer Hamidi, Hamid Yimam Hassen, Chi Linh Hoang, Mihaela Hostiuc, Zakir Hussain, Seyed Sina Naghibi Irvani, Spencer L. James, Ravi Prakash Jha, Jost B. Jonas, André Karch, Amir Kasaeian, Tesfaye Dessale Kassa, Nicholas J Kassebaum, Adane Teshome Kefale, Yousef Saleh Khader, Ejaz Ahmad Khan, Md Nuruzzaman Khan, Young-Ho Khang, Abdullah T Khoja, Ruth W Kimokoti, Adnan Kisa, Sezer Kisa, Niranjan Kissoon, Sonali Kochhar, Soewarta Kosen, Ai Koyanagi, Barthelemy Kuate Defo, G Anil Kumar, Dharmesh Kumar Lal, Cheru Tesema Leshargie, Shanshan Li, Rakesh Lodha, Erlyn Rachelle King Macarayan, Marek Majdan, Abdullah A. Mamun, Helena Manguerra, Addisu Melese, Ziad A Memish, Desalegn Tadese Mengistu, Tuomo J Meretoja, Tomislav Mestrovic, Bartosz Miazgowski, Erkin M Mirrakhimov, Babak Moazen, Karzan Abdulmuhsin Mohammad, Shafiu Mohammed, Lorenzo Monasta, Catrin E Moore, Jonathan F. Mosser, Seyyed Meysam Mousavi, Srinivas Murthy, Ghulam Mustafa, Javad Nazari, Cuong Tat Nguyen, Long Hoang Nguyen, Muhammad Imran Nisar, Molly R Nixon, Felix Akpojene Ogbo, Anselm Okoro, Andrew T Olagunju, Tinuke O Olagunju, Mahesh P A, Smita Pakhale, Maarten J Postma, Mostafa Qorbani, Reginald Quansah, Alireza Rafiei, Fakher Rahim, Vafa Rahimi-Movaghar, Rajesh Kumar Rai, Mohammad Sadegh Rezai, Aziz Rezapour, Maria Jesus Rios-Blancas, Luca Ronfani, Katherine Rosettie, Dietrich Rothenbacher, Saeed Safari, Zikria Saleem, Evanson Zondani Sambala, Abdallah M. Samy, Milena M Santric Milicevic, Benn Sartorius, Monika Sawhney, Seyedmojtaba Seyedmousavi, Masood Ali Shaikh, Aziz Sheikh, Mika Shigematsu, David L Smith, Joan B Soriano, Chandrashekhar T Sreeramareddy, Jeffrey D Stanaway, Mu'awiyyah Babale Sufiyan, Teklay G E Teklu, Mohamad-Hani Temsah, Belay Tessema, Bach Xuan Tran, Khanh Bao Tran, Irfan Ullah, Rachel L Updike, Tommi Juhani Vasankari, Yousef Veisani, Fiseha Wadilo Wada, Yasir Waheed, Marcia Weaver, Kirsten E Wiens, Charles Shey Wiysonge, Ebrahim M Yimer, Naohiro Yonemoto, Zoubida Zaidi, Heather J Zar, Afshin Zarghi, Stephen S Lim, Theo Vos, Ali H Mokdad, Christopher J L Murray, Hmwe Hmwe Kyu, Simon I. Hay, Robert C Reiner
Journal: The Lancet Infectious Diseases (2019)

Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study's comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017.This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years.Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162-593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1-87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1-74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2-15·5), childhood wasting (9·9% decrease, 9·6-10·2), and low use of oral rehydration solution (6·9% decrease, 4·8-8·4).Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors-particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution-appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness.Bill & Melinda Gates Foundation.