Understanding deaths from diarrhoea in children younger than 5 years
Authors: Ashraful Islam Khan, Mohammad Ashraful Amin
Journal: The Lancet Global Health (2024)

Despite a decrease in incidence during the past 30 years, diarrhoea continues to be a major global contributor to deaths among children younger than 5 years.1Hartman RM Cohen AL Antoni S et al.Risk factors for mortality among children younger than age 5 years with severe diarrhea in low- and middle-income countries: findings from the World Health Organization-coordinated global rotavirus and pediatric diarrhea surveillance networks.Clin Infect Dis. 2023; 76: e1047-e1053Crossref PubMed Scopus (7) Google Scholar There are various microorganisms responsible for diarrhoeal infections, such as bacteria, viruses, and parasites. Undernutrition, low weight for height, non-exclusive breastfeeding, incomplete rotavirus vaccine administration, little health-care access, and inadequate sanitation and hygiene practices are all risk factors for fatal diarrhoea in children younger than 5 years.2Acácio S Mandomando I Nhampossa T et al.Risk factors for death among children 0–59 months of age with moderate-to-severe diarrhea in Manhiça district, southern Mozambique.BMC Infect Dis. 2019; 19: 322Crossref PubMed Scopus (0) Google Scholar, 3Al Jarousha AMK El Jarou MA El Qouqa IA Bacterial enteropathogens and risk factors associated with childhood diarrhea.Indian J Pediatr. 2011; 78: 165-170Crossref PubMed Scopus (23) Google Scholar, 4Mohan VR Karthikeyan R Babji S et al.Rotavirus infection and disease in a multisite birth cohort: results from the MAL-ED study.J Infect Dis. 2017; 216: 305-316Crossref PubMed Scopus (28) Google Scholar, 5Troeger C Blacker BF Khalil IA et al.Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Infect Dis. 2018; 18: 1211-1228Summary Full Text Full Text PDF PubMed Scopus (828) Google Scholar Understanding the causes of death from diarrhoea in children with regard to specific enteric pathogens would provide global awareness of the primary causes of mortality, as well as their prevention and control strategies. The study by Black and colleagues6Black RE Perin J Yeung D et al.Estimated global and regional causes of deaths from diarrhoea in children younger than 5 years during 2000–21: a systematic review and Bayesian multinomial analysis.Lancet Glob Health. 2024; (published online April 19.)https://doi.org/10.1016/S2214-109X(24)00078-0Google Scholar examined changes in factors contributing to deaths from diarrhoea in children younger than 5 years over time, comparing data from 2000 with data from 2021. The authors selected 12 pathogens with the highest attributable incidence in the Global Enteric Multicenter Study to examine their contribution to mortality and estimated rotavirus to be the primary pathogen contributing to deaths from diarrhoea in children younger than 5 years in both low-income and middle-income countries (LMICs) and high-income countries (HICs) in both 2000 (LMICs 316 382 [26·5%] of 1 196 134, 95% uncertainty interval 25·7–28·5; HICs 252 [27·6%] of 910, 25·3–29·7) and 2021 (LMICs 108 322 [24·4%] of 443 342, 21·6–29·5; HICs 148 [30·3%] of 490, 26·9–34·1). Their systematic analysis offers valuable insights into the evolution of diarrhoea during a period of 20 years. Furthermore, their analysis accounted for diagnostic sensitivity, particularly when using quantitative PCR techniques. Their analysis also highlights the global and regional differences in factors contributing to deaths from diarrhoea in children younger than 5 years, emphasising the importance of understanding these differences. However, there are still some key issues that need to be addressed, including resurgence of cholera in some regions and finding evidence on associated factors. Researchers should explore the underlying causes of deaths from diarrhoea other than the pathogens, including malnutrition, health-care access, and socioeconomic factors, and examine the effectiveness of existing interventions, policy recommendations, and global efforts for diarrhoea prevention. For example, a rapid diagnostic test for all possible enteropathies in circumstances in which there is little access to modern facilities. Understanding the complexities of enteric coinfections, including the interactions between different pathogens, their combined effects on the progression of diarrhoea, and the potential for synergistic effects, is crucial. This understanding could reveal the complexity of diarrhoeal causes in real-life situations. To reduce morbidity and mortality linked to coinfection-associated enteric diseases, targeted treatment regimens, improved diagnostic techniques, and comprehensive surveillance are required. The discussion on estimating case–fatality rate for diarrhoeal pathogens is insightful due to the diverse rotavirus genotypes in Africa and other regions.7Mphahlele MJ Groome MJ Page NA Bhagwandin N Mwenda JM Steele AD A decade of rotavirus vaccination in Africa—saving lives and changing the face of diarrhoeal diseases: report of the 12th African Rotavirus Symposium.Vaccine. 2021; 39: 2319-2324Crossref PubMed Scopus (5) Google Scholar Currently, there is no indication that the emergence of rotavirus strains could evade immunity conferred by vaccines, but this potential issue should still be considered. Future prospects for genomic exploration of diarrhoeal pathogens should consider host–pathogen interactions, analysing the role of the gut microbiome, conducting phylogenetic and comparative genomics studies, encouraging the exchange of data, and incorporating technologies to track patterns of transmission.7Mphahlele MJ Groome MJ Page NA Bhagwandin N Mwenda JM Steele AD A decade of rotavirus vaccination in Africa—saving lives and changing the face of diarrhoeal diseases: report of the 12th African Rotavirus Symposium.Vaccine. 2021; 39: 2319-2324Crossref PubMed Scopus (5) Google Scholar, 8Huttenhower C Finn RD McHardy AC Challenges and opportunities in sharing microbiome data and analyses.Nat Microbiol. 2023; 8: 1960-1970Crossref PubMed Scopus (2) Google Scholar These strategies aim to promote focused interventions for the prevention and control of diarrhoea, improve comprehension of mechanisms, and increase diagnostic capacity. Despite the suggestive strategies from the analysis by Black and colleagues,6Black RE Perin J Yeung D et al.Estimated global and regional causes of deaths from diarrhoea in children younger than 5 years during 2000–21: a systematic review and Bayesian multinomial analysis.Lancet Glob Health. 2024; (published online April 19.)https://doi.org/10.1016/S2214-109X(24)00078-0Google Scholar there were some limitations, including data unavailability. Considering this limitation, future efforts could focus on expanding the dataset, especially from under-represented regions, to enhance the accuracy of estimates. However, this analysis updates the estimates on deaths from diarrhoea in children younger than 5 years, enhancing knowledge for policy makers, public health practitioners, and researchers working to address diarrhoea in children younger than 5 years. Global progress has been made in reducing deaths from diarrhoea in childhood by about two-thirds since 2000, but preventing the remaining substantial number of deaths remains a priority. Interventions, such as vaccination, and a comprehensive approach, including improved water, sanitation, hygiene practices and effective treatments, are crucial to overcome diarrhoea and prevent future mortality. We declare no competing interests. Estimated global and regional causes of deaths from diarrhoea in children younger than 5 years during 2000–21: a systematic review and Bayesian multinomial analysisOur results indicate progress in the reduction of deaths from diarrhoea caused by 12 pathogens in children younger than 5 years in the past two decades. There is a need to increase efforts for prevention, including with rotavirus vaccine, and treatment to eliminate further deaths. Full-Text PDF Open Access