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

GBD 2016 Diarrhoeal Disease Collaborators, Christopher Troeger, Brigette F Blacker, Ibrahim A Khalil, Puja C Rao, Shujin Cao, Stephanie Rm Zimsen, Samuel B Albertson, Jeffery D Stanaway, Aniruddha Deshpande, Zegeye Abebe, Nelson Alvis-Guzman, Azmeraw T Amare, Solomon W Asgedom, Zelalem Alamrew Anteneh, Carl Abelardo T Antonio, Olatunde Aremu, Ephrem Tsegay Asfaw, Tesfay Mehari Atey, Suleman Atique, Euripide Frinel G Arthur Avokpaho, Ashish Awasthi, Henok Tadesse Ayele, Aleksandra Barac, Mauricio L Barreto, Quique Bassat, Saba Abraham Belay, Isabela M Bensenor, Zulfiqar A Bhutta, Ali Bijani, Hailemichael Bizuneh, Carlos A Castañeda-Orjuela, Abel Fekadu Dadi, Lalit Dandona, Rakhi Dandona, Huyen Phuc Do, Manisha Dubey, Eleonora Dubljanin, Dumessa Edessa, Aman Yesuf Endries, Babak Eshrati, Tamer Farag, Garumma Tolu Feyissa, Kyle J Foreman, Mohammad H Forouzanfar, Nancy Fullman, Peter W Gething, Melkamu Dedefo Gishu, William W Godwin, Harish Chander Gugnani, Rahul Gupta, Gessessew Bugssa Hailu, Hamid Yimam Hassen, Desalegn Tsegaw Hibstu, Olayinka S Ilesanmi, Jost B Jonas, Amaha Kahsay, Gagandeep Kang, Amir Kasaeian, Yousef Saleh Khader, Ibrahim A Khalil, Ejaz Ahmad Khan, Muhammad Ali Khan, Young-Ho Khang, Niranjan Kissoon, Sonali Kochhar, Karen L Kotloff, Ai Koyanagi, G Anil Kumar, Hassan Magdy Abd El Razek, Reza Malekzadeh, Deborah Carvalho Malta, Suresh Mehata, Walter Mendoza, Desalegn Tadese Mengistu, Bereket Gebremichael Menota, Haftay Berhane Mezgebe, Fitsum Weldegebreal Mlashu, Srinivas Murthy, Gurudatta A Naik, Cuong Tat Nguyen, Trang Huyen Nguyen, Dina Nur Anggraini Ningrum, Felix Akpojene Ogbo, Andrew Toyin Olagunju, Deepak Paudel, James A Platts-Mills, Mostafa Qorbani, Anwar Rafay, Rajesh Kumar Rai, Saleem M Rana, Chhabi Lal Ranabhat, Davide Rasella, Sarah E Ray, Cesar Reis, Andre Mn Renzaho, Mohammad Sadegh Rezai, George Mugambage Ruhago, Saeid Safiri, Joshua A Salomon, Juan Ramon Sanabria, Benn Sartorius, Monika Sawhney, Sadaf G Sepanlou, Mika Shigematsu, Mekonnen Sisay, Ranjani Somayaji, Chandrashekhar T Sreeramareddy, Bryan L Sykes, Getachew Redae Taffere, Roman Topor-Madry, Bach Xuan Tran, Kald Beshir Tuem, Kingsley Nnanna Ukwaja, Stein Emil Vollset, Judd L Walson, Marcia R Weaver, Kidu Gidey Weldegwergs, Andrea Werdecker, Abdulhalik Workicho, Muluken Yenesew, Biruck Desalegn Yirsaw, Naohiro Yonemoto, Maysaa El Sayed Zaki, Theo Vos, Stephen S Lim, Mohsen Naghavi, Christopher Jl Murray, Ali H Mokdad, Simon I Hay, Robert C Reiner Jr, GBD 2016 Diarrhoeal Disease Collaborators, Christopher Troeger, Brigette F Blacker, Ibrahim A Khalil, Puja C Rao, Shujin Cao, Stephanie Rm Zimsen, Samuel B Albertson, Jeffery D Stanaway, Aniruddha Deshpande, Zegeye Abebe, Nelson Alvis-Guzman, Azmeraw T Amare, Solomon W Asgedom, Zelalem Alamrew Anteneh, Carl Abelardo T Antonio, Olatunde Aremu, Ephrem Tsegay Asfaw, Tesfay Mehari Atey, Suleman Atique, Euripide Frinel G Arthur Avokpaho, Ashish Awasthi, Henok Tadesse Ayele, Aleksandra Barac, Mauricio L Barreto, Quique Bassat, Saba Abraham Belay, Isabela M Bensenor, Zulfiqar A Bhutta, Ali Bijani, Hailemichael Bizuneh, Carlos A Castañeda-Orjuela, Abel Fekadu Dadi, Lalit Dandona, Rakhi Dandona, Huyen Phuc Do, Manisha Dubey, Eleonora Dubljanin, Dumessa Edessa, Aman Yesuf Endries, Babak Eshrati, Tamer Farag, Garumma Tolu Feyissa, Kyle J Foreman, Mohammad H Forouzanfar, Nancy Fullman, Peter W Gething, Melkamu Dedefo Gishu, William W Godwin, Harish Chander Gugnani, Rahul Gupta, Gessessew Bugssa Hailu, Hamid Yimam Hassen, Desalegn Tsegaw Hibstu, Olayinka S Ilesanmi, Jost B Jonas, Amaha Kahsay, Gagandeep Kang, Amir Kasaeian, Yousef Saleh Khader, Ibrahim A Khalil, Ejaz Ahmad Khan, Muhammad Ali Khan, Young-Ho Khang, Niranjan Kissoon, Sonali Kochhar, Karen L Kotloff, Ai Koyanagi, G Anil Kumar, Hassan Magdy Abd El Razek, Reza Malekzadeh, Deborah Carvalho Malta, Suresh Mehata, Walter Mendoza, Desalegn Tadese Mengistu, Bereket Gebremichael Menota, Haftay Berhane Mezgebe, Fitsum Weldegebreal Mlashu, Srinivas Murthy, Gurudatta A Naik, Cuong Tat Nguyen, Trang Huyen Nguyen, Dina Nur Anggraini Ningrum, Felix Akpojene Ogbo, Andrew Toyin Olagunju, Deepak Paudel, James A Platts-Mills, Mostafa Qorbani, Anwar Rafay, Rajesh Kumar Rai, Saleem M Rana, Chhabi Lal Ranabhat, Davide Rasella, Sarah E Ray, Cesar Reis, Andre Mn Renzaho, Mohammad Sadegh Rezai, George Mugambage Ruhago, Saeid Safiri, Joshua A Salomon, Juan Ramon Sanabria, Benn Sartorius, Monika Sawhney, Sadaf G Sepanlou, Mika Shigematsu, Mekonnen Sisay, Ranjani Somayaji, Chandrashekhar T Sreeramareddy, Bryan L Sykes, Getachew Redae Taffere, Roman Topor-Madry, Bach Xuan Tran, Kald Beshir Tuem, Kingsley Nnanna Ukwaja, Stein Emil Vollset, Judd L Walson, Marcia R Weaver, Kidu Gidey Weldegwergs, Andrea Werdecker, Abdulhalik Workicho, Muluken Yenesew, Biruck Desalegn Yirsaw, Naohiro Yonemoto, Maysaa El Sayed Zaki, Theo Vos, Stephen S Lim, Mohsen Naghavi, Christopher Jl Murray, Ali H Mokdad, Simon I Hay, Robert C Reiner Jr

Abstract

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990-2016 and assesses how the burden of diarrhoea has changed in people of all ages.

Methods: We modelled diarrhoea mortality with a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We modelled diarrhoea incidence with a compartmental meta-regression tool that enforces an association between incidence and prevalence, and relies on scientific literature, population representative surveys, and health-care data. Diarrhoea deaths and episodes were attributed to 13 pathogens by use of a counterfactual population attributable fraction approach. Diarrhoea risk factors are also based on counterfactual estimates of risk exposure and the association between the risk and diarrhoea. Each modelled estimate accounted for uncertainty.

Findings: In 2016, diarrhoea was the eighth leading cause of death among all ages (1 655 944 deaths, 95% uncertainty interval [UI] 1 244 073-2 366 552) and the fifth leading cause of death among children younger than 5 years (446 000 deaths, 390 894-504 613). Rotavirus was the leading aetiology for diarrhoea mortality among children younger than 5 years (128 515 deaths, 105 138-155 133) and among all ages (228 047 deaths, 183 526-292 737). Childhood wasting (low weight-for-height score), unsafe water, and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80·4% (95% UI 68·2-85·0), 72·1% (34·0-91·4), and 56·4% (49·3-62·7) of diarrhoea deaths in children younger than 5 years, respectively. Prevention of wasting in 1762 children (95% UI 1521-2170) could avert one death from diarrhoea.

Interpretation: Substantial progress has been made globally in reducing the burden of diarrhoeal diseases, driven by decreases in several primary risk factors. However, this reduction has not been equal across locations, and burden among adults older than 70 years requires attention.

Funding: Bill & Melinda Gates Foundation.

Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1
Figure 1
Diarrhoea mortality rate in 2016 Diarrhoea mortality rate in individuals of all ages (A), children younger than 5 years (B), and adults older than 70 years (C). U5MR=under-5 mortality rate. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. Isl=Islands. FSM=Federated States of Micronesia. TLS=Timor-Leste.
Figure 1
Figure 1
Diarrhoea mortality rate in 2016 Diarrhoea mortality rate in individuals of all ages (A), children younger than 5 years (B), and adults older than 70 years (C). U5MR=under-5 mortality rate. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. Isl=Islands. FSM=Federated States of Micronesia. TLS=Timor-Leste.
Figure 2
Figure 2
Assocation between the Socio-demographic Index and diarrhoea case fatality in children younger than 5 years in 2016 Each point represents a country.
Figure 3
Figure 3
Reduction in under-5 mortality rate due to diarrhoea, 2000–16
Figure 4
Figure 4
Heat map of the number of children younger than 5 years that were needed to treat to prevent a diarrhoea death in 2016 Countries are ordered by the diarrhoea mortality rate among children younger than 5 years into deciles from Chad (highest mortality rate) to Finland (lowest mortality rate).
Figure 4
Figure 4
Heat map of the number of children younger than 5 years that were needed to treat to prevent a diarrhoea death in 2016 Countries are ordered by the diarrhoea mortality rate among children younger than 5 years into deciles from Chad (highest mortality rate) to Finland (lowest mortality rate).
Figure 4
Figure 4
Heat map of the number of children younger than 5 years that were needed to treat to prevent a diarrhoea death in 2016 Countries are ordered by the diarrhoea mortality rate among children younger than 5 years into deciles from Chad (highest mortality rate) to Finland (lowest mortality rate).

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