Early childhood diarrhoea: from data to interventions
Authors: Karen H Keddy
Journal: The Lancet Infectious Diseases (2019)

The Global Burden of Diseases (GBD) project was originally commissioned by the World Bank in 1990, with the intent to define disease burdens and optimise interventions depending on local resources.1Lopez AD Mathers C Ezzati M Jamison DT Murray CJ Measuring the global burden of disease and risk factors, 1990–2001.in: Lopez AD Mathers C Ezzati M Jamison DT Murray CJ Global Burden of Disease and Risk Factors. Oxford University Press, New York2006: 1-13Crossref Google Scholar The excessive uncertainty of results regarding certain countries due to absent or poor data was problematic and meant that those countries that would most benefit from the information could be disadvantaged by inappropriate interventions based on questionable data.2Cooper RS Osotimehin B Kaufman JS Forrester T Disease burden in sub-Saharan Africa: what should we conclude in the absence of data?.Lancet. 1998; 351: 208-210Summary Full Text Full Text PDF PubMed Scopus (102) Google Scholar 30 years after the project was initiated, the GBD 2017 Diarrhoeal Disease Collaborators have produced an Article3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar that answers, in part, the question regarding optimal interventions. Analysing the data at a country level, the authors have defined a hierarchy of interventions that have decreased diarrhoea burdens and mortality in the vulnerable population of children younger than 5 years.3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar Knowledge and understanding of what interventions for diarrhoea are appropriate has been well examined4Darvesh N Das JK Vaivada T Gaffey MF Rasanathan K Bhutta ZA Water, sanitation and hygiene interventions for acute childhood diarrhea: a systematic review to provide estimates for the Lives Saved Tool.BMC Public Health. 2017; 17: 776Crossref PubMed Scopus (69) Google Scholar, 5Wolf J Hunter PR Freeman MC et al.Impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta-analysis and meta-regression.Trop Med Int Health. 2018; 23: 508-525Crossref PubMed Scopus (194) Google Scholar, 6Das JK Lassi ZS Salam RA Bhutta ZA Effect of community based interventions on childhood diarrhea and pneumonia: uptake of treatment modalities and impact on mortality.BMC Public Health. 2013; 13: S29Crossref PubMed Scopus (55) Google Scholar but challenges remain because the multipronged approach that is normally advocated might be overwhelming in severely resource-constrained countries. By quantifying which interventions might have had the greatest effect on diarrhoea burdens in children younger than 5 years, the authors have provided an evidence base that will allow under-resourced countries to prioritise and scale up those interventions that are most likely to assist them in achieving the Sustainable Development Goal 4. Specifically, the analysis included interventions to improve water, sanitation, and hygiene (WASH), increase rotavirus vaccine coverage, curb zinc and vitamin A deficiency, reduce the prevalence of childhood stunting and underweight, increase use of oral rehydration solution, prevent low birthweight and short gestation, and eliminate suboptimal breastfeeding.3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar Globally, there was a 69·6% decrease (95% uncertainty interval [UI] 63·1–74·6) in under-5 diarrhoea mortality between 1990 and 2017, corresponding to 179·5 fewer deaths (149·2–207·1) per 100 000 children. The factor that contributed the most to this decline was a decrease in unsafe sanitation (13·3%).3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar Of note, at a regional or country level, the effect of selected interventions differed; for example, the countries in the 5th quintile of decrease in diarrhoea mortality rate (ie, had the greatest decrease) had the greatest improvement in childhood undernutrition, whereas improvements in the provision of WASH was associated with the fourth quintile of improvements in diarrhoeal mortality.3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar At a national level, the Article highlights some interesting observations. Despite the overwhelming overall improvement in diarrhoeal morbidity and mortality in children younger than 5 years between 1990 and 2017, a few important exceptions were noted: the net mortality rate increased in Zimbabwe (6·1 additional deaths [95% UI 1·8–11·1] per 100 000 children) and Central African Republic (241·4 additional deaths [114·6–430·5] per 100 000 children), despite improvements in breast-feeding practices, rotavirus vaccine coverage, and management of vitamin A deficiency.3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar The increases in mortality rate are probably due to the economic and political instability in these two countries in recent years: Zimbabwe had an economic meltdown and the Central African Republic accounted for 25% of all the non-state (ie, faction-related) battle deaths in Africa in 2017. Simultaneously, the greatest improvements in childhood nutrition was noted in countries emerging from political or social turmoil. For example, in Angola (where the civil war ended in 2002) under-5 diarrhoea mortality rate due to wasting decreased by 53·9% (1990–2017) and in Laos (which is gradually emerging from the conflict of the previous century and is decentralising certain financial controls) under-5 diarrhoea mortality rate due to wasting decreased by 55·2%.3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar Despite experiencing the worst cholera epidemic in epidemiologically recorded history with over 1·1 million cases,7Camacho A Bouhenia M Alyusfi R et al.Cholera epidemic in Yemen, 2016–18: an analysis of surveillance data.Lancet Glob Health. 2018; 6: e680-e690Summary Full Text Full Text PDF PubMed Scopus (97) Google Scholar Yemen showed an 80·4% (66·7–87·6) decrease in under-5 diarrhoea mortality rate.3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar Given the political instability in some countries where improvements in childhood diarrhoea mortality rates have been noted, it is important that this type of analysis continues. In some highly developed economies—including some countries in western Europe, New Zealand, Australia, Japan, and the USA—a small increase was found in the under-5 diarrhoea mortality rate. This increase is primarily due to a greater prevalence of low birthweight and short gestational age,3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar possibly as a result of improvements in peripartum care in these countries over the last three decades, which have resulted in fewer intrauterine deaths, but an increase in vulnerable, preterm infants.8Norris T Manktelow BN Smith LK Draper ES Causes and temporal changes in nationally collected stillbirth audit data in high-resource settings.Semin Fetal Neonatal Med. 2017; 22: 118-128Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar Researchers will hopefully use results of the meticulous and complex analysis done by the GBD 2017 diarrhoeal disease collaborators3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar to further develop their own in-country analyses to optimise interventions to decrease the burden of childhood diarrhoea. As some of the interventions, such as improved childhood undernutrition and correction of micronutrient deficiencies,6Das JK Lassi ZS Salam RA Bhutta ZA Effect of community based interventions on childhood diarrhea and pneumonia: uptake of treatment modalities and impact on mortality.BMC Public Health. 2013; 13: S29Crossref PubMed Scopus (55) Google Scholar might affect other disease syndromes, their introduction should result in improved early childhood survival generally. The earlier attempts at defining the burden of childhood diarrhoea were laudable and necessary to enable the global community to define interventions in those areas where disease burdens were calculable,2Cooper RS Osotimehin B Kaufman JS Forrester T Disease burden in sub-Saharan Africa: what should we conclude in the absence of data?.Lancet. 1998; 351: 208-210Summary Full Text Full Text PDF PubMed Scopus (102) Google Scholar as much as to understand where data gaps existed.1Lopez AD Mathers C Ezzati M Jamison DT Murray CJ Measuring the global burden of disease and risk factors, 1990–2001.in: Lopez AD Mathers C Ezzati M Jamison DT Murray CJ Global Burden of Disease and Risk Factors. Oxford University Press, New York2006: 1-13Crossref Google Scholar The GBD 2017 diarrhoeal disease collaborators have provided a critical service: their work3GBD 2017 Diarrhoeal Disease CollaboratorsQuantifying 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.Lancet Infect Dis. 2019; (published online Oct 30)https://doi.org/10.1016/S1473-3099(19)30401-3Google Scholar should incentivise resource-constrained countries to implement interventions for childhood diarrhoea, tailored according to their own national and subnational needs. I declare no competing interests. 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 2017Diarrhoea 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. Full-Text PDF Open Access