Childhood mortality due to diarrhea remains high in some regions as a result of a combination of child growth failure, poor access to water, sanitation, and hygiene, and low oral rehydration therapy coverage, according to results of a study published in The Lancet.

Diarrhea was found to be the third leading cause of death among children aged < 5 years and responsible for an estimated 534,000 deaths in the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. By establishing good health practices, preventing infections from occurring, and treating infections when they occur, the World Health Organization’s Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea aims to reduce childhood mortality due to diarrhea.

Large reductions of mortality have been observed in low-income and middle-income countries over the last decade with the help of strategies to reduce child growth failure, improve access to water, sanitation and hygiene, and increasing access to vaccines and oral rehydration therapy. Previous studies have observed a substantial variation between countries in both the likelihood of a child experiencing an episode of diarrhea and that episode resulting in death. In order to reduce the burden in the remaining subnational regions with the highest prevalence and those with the lowest levels of interventions, those regions must first be identified. Therefore, this study analyzed the local variation in diarrheal morbidity and mortality in children aged < 5 years across 94 in low-income and middle-income countries between 2000 and 2017.

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In total, 15,072,746 children aged < 5 years from 466 surveys in 94 in low-income and middle-income countries were included from a geolocated dataset. Bayseian model-based geostatistics and findings from the Global Burden of Diseases 2017 were used in combination with this dataset to estimate posterior distributions of diarrhea prevalence, incidence, and mortality from 2000 to 2017. The burden of diarrhea at varying subnational levels (termed units by the study authors) was estimated and the drivers of subnational patterns were investigated.

Results showed that improvements in access to water, sanitation and hygiene or reductions in child growth failure were correlated with reductions in mortality. Over the last 18 years, although 5729 (24%) units saw an increase in childhood diarrhea, only 112 (0.5%) units reported an increase in mortality rates. The south and southeast regions of Asia and South America were identified as regions with the greatest declines in diarrheal mortality, where 54.0% and 59.5% units, respectively, recorded >10% decreases in deaths due to diarrhea. The region with the highest morality units was Pakistan. The greatest geographic inequality within a country was observed in Indonesia, with some regions having a mortality rate 4-times higher than that of the average country rate. Most of the high-risk areas had some combination of poor water, sanitation and hygiene, high child growth failure, and low oral rehydration therapy coverage.

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Overall, the study authors concluded that, “This work provides the data necessary to formulate effective policies and precision public health programs to ultimately stop the preventable loss of so many young lives.”


Reiner RC and Hay SI. Mapping geographical inequalities in childhood diarrheal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis from the Global Burden of Disease Study 2017 [published online May 6, 2020]. The Lancet. doi:10.1016/S0140-6736(20)30114-8