brand logo

KRISTINA BURGERS, MD, BRIANA LINDBERG, MD, AND ZACHARY J. BEVIS, MD

Am Fam Physician. 2020;101(8):472-480

Patient information: See related handout on chronic diarrhea , written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Chronic diarrhea is defined as a predominantly loose stool lasting longer than four weeks. A patient history and physical examination with a complete blood count, C-reactive protein, anti-tissue transglutaminase immunoglobulin A (IgA), total IgA, and a basic metabolic panel are useful to evaluate for pathologies such as celiac disease or inflammatory bowel disease. More targeted testing should be based on the differential diagnosis. When the differential diagnosis is broad, stool studies should be used to categorize diarrhea as watery, fatty, or inflammatory. Some disorders can cause more than one type of diarrhea. Watery diarrhea includes secretory, osmotic, and functional types. Functional disorders such as irritable bowel syndrome and functional diarrhea are common causes of chronic diarrhea. Secretory diarrhea can be caused by bile acid malabsorption, microscopic colitis, endocrine disorders, and some postsurgical states. Osmotic diarrhea can present with carbohydrate malabsorption syndromes and laxative abuse. Fatty diarrhea can be caused by malabsorption or maldigestion and includes disorders such as celiac disease, giardiasis, and pancreatic exocrine insufficiency. Inflammatory diarrhea warrants further evaluation and can be caused by disorders such as inflammatory bowel disease, Clostridioides difficile , colitis, and colorectal cancer.

Chronic diarrhea is defined as a predominantly decreased stool consistency lasting longer than four weeks. 1 , 2 The prevalence is estimated to be 1% to 5% of the adult population. 1 Common causes include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), celiac disease, and microscopic colitis. The differential diagnosis for chronic diarrhea is broad; however, a thorough history and physical examination can narrow the diagnostic evaluation. The British Society of Gastroenterology published guidelines for the evaluation of chronic diarrhea, and other authors suggest similar diagnostic approaches, but supporting evidence is weak. 1 , 2 The recommendations in this article are based on the evidence available and published guidelines for the evaluation of causes of chronic diarrhea. Figure 1 is an algorithm for the diagnosis of chronic diarrhea. 1 – 4

literature review of diarrhea

Most patients use the word diarrhea to describe loose stools 3 ; however, some patients may use it to describe fecal urgency, frequency, or incontinence. 2 The Bristol Stool Scale ( https://www.aafp.org/afp/2011/0801/p299.html#afp20110801p299-f1 ) is helpful in distinguishing diarrhea from pseudodiarrhea. 5 This article covers diarrhea as it is commonly defined in the medical literature (i.e., Bristol types 5 to 7). 2 , 3

Clinicians should ask patients about key historical features, including stool appearance and odor, the presence of urgency or tenesmus, pain, the frequency and duration of symptoms, whether diarrhea persists at night or with fasting, and possible triggers. 2 , 4 A thorough travel and dietary history can help guide the clinician toward an appropriate workup for infections or food intolerance. A review of systems can reveal extraintestinal manifestations of the disease. A complete medication history, including over-the-counter medications, illicit drug use, alcohol use, and supplements, is indicated. Table 1 lists medications commonly associated with diarrhea 6 ; however, a patient can experience diarrhea from almost any medication. 1 , 4 A discussion of current medical diagnoses and any prior surgical procedures may identify an etiology. A behavioral health history should be obtained, including the psychosocial impact of symptoms on the patient and potential secondary gain. Documentation from any previous office visits, laboratory testing, and diagnostic procedures should be obtained before further testing. 4 Table 2 lists clues to specific diagnoses. 1 – 4 , 6 – 21 Diagnoses affecting immunocompromised patients with chronic diarrhea are beyond the scope of this article.

Physical Examination

A thorough physical examination, including abdominal examination, visual inspection of the anus and perianal skin, and a digital rectal examination, is indicated for any patient who reports chronic diarrhea. Office anoscopy can be helpful in suspected inflammatory disorders.

Diagnostic Approach

The initial laboratory workup should include a complete blood count, C-reactive protein (CRP) level, anti-tissue transglutaminase immunoglobulin A (IgA) level, total IgA level, and a basic metabolic panel. 1 , 8 , 22 The diagnostic evaluation should be guided by history and physical examination. Alarm features such as anemia, unintentional weight loss, and persistent blood in the stool warrant further investigation. 1 , 2 , 4 A patient who meets Rome IV diagnostic criteria ( Table 3 3 ) for IBS, has routine physical examination and initial laboratory results, and has no alarm features may be diagnosed with IBS. 3

Magnetic resonance imaging or computed tomography imaging with enterography may be performed for patients with alarm features, abnormal laboratory values, or suspected structural disease. 4 Colonoscopy should also be performed for patients with alarm features or for whom a reasonable initial workup has failed to yield a diagnosis. When colonoscopy is performed to evaluate chronic diarrhea, multiple mucosal biopsies should be taken, even if the endoscopic mucosal appearance is normal. 23

When the initial evaluation fails to narrow the differential diagnosis, testing for fecal occult blood (i.e., fecal immunochemistry test), fecal calprotectin (i.e., leukocytes or lactoferrin), and fecal fat (i.e., Sudan stain) may be helpful to categorize diarrhea as watery, fatty, or inflammatory. 1 , 4 Although this can help narrow the differential diagnosis, it is important to understand that some disorders can cause more than one type of diarrhea.

These three categories can be subdivided further based on a comprehensive fecal analysis including a 24-hour stool mass for the quantification of diarrhea and calculation of fecal components, quantitative fecal fat test (i.e., 24- to 48-hour chemical analysis or quantitative Sudan microscopy), and fecal chemistry test (i.e., pH level, osmolality, electrolytes, and phosphate). 24 , 25 However, these tests are not always readily available and usefulness varies. 1 , 2 When available, they can be helpful in diagnosing a factitious disorder and surreptitious laxative use. 25

Watery diarrhea is a loose stool that does not contain leukocytes, lactoferrin or calprotectin, blood, or elevated levels of fecal fat. It can be separated into secretory, osmotic, and functional types. Secretory diarrhea is caused by reduced water absorption, and results in high stool volumes; symptoms persist at night and during fasting. Osmotic diarrhea is caused by water retention in the intestine because of the presence of poorly absorbed solutes; stool analysis revealing high stool osmotic gaps can help distinguish it from other watery diarrheas. 7 Functional disorders lack a clear organic etiology and are diagnosed using Rome IV diagnostic criteria. The predominance of pain differentiates between IBS and functional diarrhea.

Fatty diarrhea, characterized by elevated levels of fecal fat, is broken down into malabsorptive and maldigestive types, based on etiology. 7

Inflammatory diarrhea is characterized by the presence of fecal leukocytes, lactoferrin or calprotectin, or blood. Further investigation of inflammatory diarrhea, including advanced imaging and colonoscopy, is always warranted. 1 , 2 , 4

Common Causes

Irritable bowel syndrome (watery – functional).

Current studies indicate that IBS has a prevalence of 9% to 23% worldwide. If a patient meets Rome IV diagnostic criteria ( Table 3 ; https://www.mdcalc.com/rome-iv-diagnostic-criteria-irritable-bowel-syndrome-ibs ) and does not have any alarm features, an extensive workup is not typically recommended. 3 It is reasonable to order a complete blood count, CRP (or stool calprotectin), basic metabolic panel, and celiac serology, based on expert opinion and American College of Gastroenterology guidelines for the evaluation of celiac disease. 3 , 4 , 8 IBS symptoms may sometimes be the presentation of other medical causes of chronic diarrhea, including nonallergic food intolerance and bile acid malabsorption. 4 Patients who do not respond to typical IBS treatments may benefit from evaluation for additional diagnoses. There may be an association between small intestinal bacterial overgrowth and IBS; however, there is no definitive evidence that small intestinal bacterial overgrowth causes IBS symptoms. If there is a clinical concern, a glucose breath test can provide additional insight. 26

FUNCTIONAL DIARRHEA (WATERY – FUNCTIONAL)

Functional diarrhea is distinct from IBS. Rome IV diagnostic criteria for functional diarrhea are “loose or watery stools, without predominant abdominal pain or bothersome bloating, occurring in greater than 25% of stools” for the past three months, with the onset of symptoms at least six months before diagnosis. Patients who meet the criteria for IBS cannot receive a diagnosis of functional diarrhea. The prevalence of functional diarrhea in adults may be as high as 17%. Functional diarrhea should be diagnosed after a reasonable effort at evaluating for organic disease. Lack of improvement with empiric loperamide (Imodium) should prompt reconsideration of the diagnosis. 3

BILE ACID MALABSORPTION (WATERY – SECRETORY)

Bile acid malabsorption is the failure of enterohepatic reabsorption of bile acids in the terminal ileum. It has been found in up to 35% of patients with IBS and microscopic colitis, and it is the underlying reason for diarrhea in ileal disease such as Crohn disease. 11 Diarrhea commonly seen after cholecystectomy is attributed to bile acid malabsorption. 1 The selenium homotaurocholic acid test is used to diagnose bile acid malabsorption in other countries but is not approved by the U.S. Food and Drug Administration. Where available, serum 7α-hydroxy-4-cholesten-3-one (elevated in bile acid malabsorption) and fibroblast growth factor 19 (low in bile acid malabsorption) have shown promise as initial tests. 27 Diagnosis can be made by starting patients on bile acid binders (i.e., cholestyramine [Questran]) and monitoring for improvement.

MICROSCOPIC COLITIS (WATERY – SECRETORY)

Microscopic colitis is estimated to cause 10% to 15% of all secretory diarrheas and is also present in 5% to 10% of patients who are diagnosed with IBS. 4 , 14 Typically, this disease presents in women around 60 years of age, although 25% of occurrences are in women younger than 45 years. The underlying mechanism is unclear; however, it has been associated with celiac disease, suggesting an autoimmune component. Medications such as proton pump inhibitors and nonsteroidal anti-inflammatory drugs have also been implicated. Symptoms include watery diarrhea, abdominal pain, weight loss, arthralgias, and fatigue. A diagnosis is made by colonoscopy with random biopsies because the gross appearance is typically normal. 15

INFLAMMATORY BOWEL DISEASE (INFLAMMATORY, WATERY – SECRETORY)

IBD encompasses the diagnoses of Crohn disease and ulcerative colitis. Onset is typically between 10 and 40 years of age. 13 The prevalence in North America is 249 per 100,000 people for ulcerative colitis and 319 per 100,000 people for Crohn disease. 28 First-degree relatives of patients with IBD are at a 10-fold increased risk of developing IBD themselves. 29 Although IBD is usually associated with inflammatory diarrhea, Crohn disease can cause secretory diarrhea. Crohn disease also is commonly associated with extraintestinal manifestations such as arthralgias and erythema nodosum. 13 Patients with IBS symptoms and a CRP level less than 0.5 mg per L (4.76 nmol per L) or fecal calprotectin level less than 40 mcg per g have a less than 1% chance of having IBD. 30 However, neither CRP nor fecal calprotectin can rule out IBD when clinical suspicion is high or alarm features are present. 13

CELIAC DISEASE (FATTY – MALABSORPTIVE, WATERY – OSMOTIC)

Celiac disease, also known as celiac sprue or gluten-sensitive enteropathy, usually causes malabsorptive fatty diarrhea, but it can also cause osmotic diarrhea through bile acid malabsorption. 4 It has a prevalence of 0.71% in the United States, is more common among whites and women, 31 and the prevalence among those with chronic diarrhea may be as high as 5%. 4 Prevalence in first- and second-degree relatives is 5% to 20%. 8 Extraintestinal manifestations include dermatitis herpetiformis, neurologic symptoms, iron deficiency anemia, and metabolic bone disease. 32 Clinicians should obtain serum anti-tissue transglutaminase and total IgA levels for all patients with chronic diarrhea for whom an apparent alternative diagnosis does not exist, 8 including patients meeting criteria for IBS or functional diarrhea. 1 , 4

The diagnosis is confirmed with an upper gastrointestinal endoscopy with duodenal biopsies. When there is a high index of suspicion, duodenal biopsies should be obtained despite normal serology. Patients who are already following a gluten-free diet may have negative antibodies and normal biopsies. 8 For those patients, celiac disease can be ruled out if genetic testing for human leukocyte antigen class II DQ2 and DQ8 molecules are negative. 8 Celiac disease should be differentiated from nonceliac gluten sensitivity, a disorder with similar symptoms but no celiac-specific antibodies, intestinal structure changes, or evidence of malabsorption. 9 A diagnosis of celiac disease carries serious health consequences for even small amounts of gluten consumption and considerations for family members; therefore, all efforts should be made to distinguish actual celiac disease from clinically similar disorders. 8

CLOSTRIDIOIDES DIFFICILE COLITIS (INFLAMMATORY)

Most infectious diarrhea is acute and self-limited, but some infections can cause chronic symptoms. One of the most notable of these in resource-rich geographic areas is C. difficile infection, which is commonly associated with antibiotic use and health care environments. Asymptomatic C. difficile colonization is common and found in up to 15% of healthy adults, and not all strains produce toxins. 10 , 21 When antibiotics alter normal gut flora, toxigenic strains of C. difficile can overgrow and produce toxins A and B. These toxins cause inflammatory diarrhea and can lead to the formation of bacterial pseudomembranes. 10 Diagnosis is best made with a stool nucleic acid amplification test. Clinicians should only test diarrheal stools to avoid false positives. 21

OTHER INFECTIONS (PRIMARY INFLAMMATORY)

Travel to resource-poor environments is a risk factor for many other infectious causes, and so is the consumption of untreated water, unwashed produce, raw dairy, and undercooked meat. In these instances, parasites are more likely than bacteria or viruses to cause chronic diarrhea in immunocompetent patients. Giardiasis is a waterborne, noninvasive, small bowel protozoal infection that leads to malabsorptive diarrhea. If infection is suspected, a stool antigen test is more sensitive than stool examination for ova and parasites. Entamoeba histolytica causes an invasive protozoal infection, usually acquired through the fecal-oral route, that leads to inflammatory diarrhea. Diagnosis is initially made through stool examination for ova and parasites, but this can be falsely positive for nonpathogenic Entamoeba species. Diagnosis can be confirmed with serology or tissue biopsy. Cryptosporidium and Cyclospora are common causes of travelers' diarrhea but can be acquired domestically. Helminth infections, such as Trichuris trichiura (i.e., whipworm) and Ascaris lumbricoides (i.e., roundworm), can usually be diagnosed with stool examination, but specific serologies can increase diagnostic yield when clinical suspicion is high. Eosinophilia is a common laboratory finding. When using stool ova and parasites for diagnosis, testing more than one sample increases the diagnostic yield. 12

Chronic bacterial diarrhea is uncommon. Some known pathogens include Tropheryma whippelii (i.e., Whipple disease), Yersinia enterocolitica , and Mycobacterium tuberculosis . Diagnosis requires a high index of suspicion. 12

ENDOCRINE DISORDERS (SECRETORY)

Endocrine disorders such as hyperthyroidism, Addison disease, and diabetes mellitus should be suspected as underlying pathologies in disordered gut motility or auto-immune enteropathy when other signs or symptoms of these disorders are present. Endocrine tumors such as carcinoid, VIPomas, and gastrinomas (i.e., Zollinger-Ellison syndrome) are rare. Levels of serum peptides (e.g., gastrin, calcitonin, vasoactive intestinal) should be obtained for patients with images of an endocrine tumor or for patients whose watery diarrhea is undiagnosed despite an appropriate evaluation. 4

This article updates a previous article on this topic by Juckett and Trivedi . 6

Data Sources: A PubMed search was completed in Clinical Queries using the key terms chronic diarrhea evaluation, chronic diarrhea guidelines, and diagnosis (conditions listed in Table 2 ). The searches included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Cochrane database, UpToDate, the Trip database, and Essential Evidence Plus. Search dates: September 2018 to January 2019, and December 2019.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Defense, the U.S. Army Medical Corps, or the U.S. Army at large.

Schiller LR, Pardi DS, Sellin JH. Chronic diarrhea: diagnosis and management. Clin Gastroenterol Hepatol. 2017;15(2):182-193.e3.

Arasaradnam RP, Brown S, Forbes A, et al. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018;67(8):1380-1399.

Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150(6):1393-1407.

Schiller LR. Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine. Am J Gastroenterol. 2018;113(5):660-669.

O'Donnell LJ, Virjee J, Heaton KW. Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate. BMJ. 1990;300(6722):439-440.

Juckett G, Trivedi R. Evaluation of chronic diarrhea. Am Fam Physician. 2011;84(10):1119-1126. https://www.aafp.org/afp/2011/1115/p1119.html

Schiller LR, Sellin JH. Diarrhea. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 10th ed . Elsevier-Saunders; 2016:221–241e5.

Rubio-Tapia A, Hill ID, Kelly CP, et al. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. 2013;108(5):656-677.

Elli L, Branchi F, Tomba C, et al. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World J Gastroenterol. 2015;21(23):7110-7119.

Sell J, Dolan B. Common gastrointestinal infections. Prim Care. 2018;45(3):519-532.

Vijayvargiya P, Camilleri M, Shin A, et al. Methods for diagnosis of bile acid malabsorption in clinical practice. Clin Gastroenterol Hepatol. 2013;11(10):1232-1239.

Kaiser L, Surawicz CM. Infectious causes of chronic diarrhoea. Best Pract Res Clin Gastroenterol. 2012;26(5):563-571.

Sairenji T, Collins KL, Evans DV. An update on inflammatory bowel disease. Prim Care. 2017;44(4):673-692.

Cotter TG, Pardi DS. Current approach to the evaluation and management of microscopic colitis. Curr Gastroenterol Rep. 2017;19(2):8.

Gentile N, Yen EF. Prevalence, pathogenesis, diagnosis, and management of microscopic colitis. Gut Liver. 2018;12(3):227-235.

Cheon JH, Kim WH. An update on the diagnosis, treatment, and prognosis of intestinal Behçet's disease. Curr Opin Rheumatol. 2015;27(1):24-31.

Syed U, Ching Companioni RA, Alkhawam H, et al. Amyloidosis of the gastrointestinal tract and the liver: clinical context, diagnosis and management. Eur J Gastroenterol Hepatol. 2016;28(10):1109-1121.

Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med. 2016;374(10):959-968.

Smith RC, Smith SF, Wilson J, et al.; Working Party of the Australasian Pancreatic Club. Summary and recommendations from the Austral-asian guidelines for the management of pancreatic exocrine insufficiency. Pancreatology. 2016;16(2):164-180.

Kuipers EJ, Grady WM, Lieberman D, et al. Colorectal cancer. Nat Rev Dis Primers. 2015;1:15065.

Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498.

Srinivas M, Basumani P, Podmore G, et al. Utility of testing patients, on presentation, for serologic features of celiac disease. Clin Gastroenterol Hepatol. 2014;12(6):946-952.

Shah RJ, Fenoglio-Preiser C, Bleau BL, et al. Usefulness of colonoscopy with biopsy in the evaluation of patients with chronic diarrhea. Am J Gastroenterol. 2001;96(4):1091-1095.

Fine KD, Ogunji F. A new method of quantitative fecal fat microscopy and its correlation with chemically measured fecal fat output. Am J Clin Pathol. 2000;113(4):528-534.

Steffer KJ, Santa Ana CA, Cole JA, et al. The practical value of comprehensive stool analysis in detecting the cause of idiopathic chronic diarrhea. Gastroenterol Clin North Am. 2012;41(3):539-560.

Rana SV, Malik A. Breath tests and irritable bowel syndrome. World J Gastroenterol. 2014;20(24):7587-7601.

Vijayvargiya P, Camilleri M, Carlson P, et al. Performance characteristics of serum C4 and FGF19 measurements to exclude the diagnosis of bile acid diarrhoea in IBS-diarrhoea and functional diarrhoea. Aliment Pharmacol Ther. 2017;46(6):581-588.

Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54.e42.

Orholm M, Munkholm P, Langholz E, et al. Familial occurrence of inflammatory bowel disease. NEngl JMed. 1991;324(2):84-88.

Menees SB, Powell C, Kurlander J, et al. A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS. Am J Gastroenterol. 2015;110(3):444-454.

Rubio-Tapia A, Ludvigsson JF, Brantner TL, et al. The prevalence of celiac disease in the United States. Am J Gastroenterol. 2012;107(10):1538-1544.

Kamboj AK, Oxentenko AS. Clinical and histologic mimickers of celiac disease. Clin Transl Gastroenterol. 2017;8(8):e114.

Continue Reading

literature review of diarrhea

More in AFP

More in pubmed.

Copyright © 2020 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • View all journals
  • Explore content
  • About the journal
  • Publish with us
  • Sign up for alerts
  • Review Article
  • Published: 23 September 2008

Mechanisms of infectious diarrhea

  • Udayakumar Navaneethan 1 &
  • Ralph A Giannella 1  

Nature Clinical Practice Gastroenterology & Hepatology volume  5 ,  pages 637–647 ( 2008 ) Cite this article

3565 Accesses

113 Citations

12 Altmetric

Metrics details

Infectious diarrhea is an important public health problem worldwide. Research has provided new insights into the mechanisms of diarrhea caused by various pathogens that are classified as noninflammatory, inflammatory or invasive. These three groups of organisms cause two diarrheal syndromes—noninflammatory diarrhea and inflammatory diarrhea. The noninflammatory diarrheas are caused by enterotoxin-producing organisms such as Vibrio cholerae and enterotoxigenic Escherichia coli , or by viruses that adhere to the mucosa and disrupt the absorptive and/or secretory processes of the enterocyte without causing acute inflammation or mucosal destruction. Inflammatory diarrhea is caused by two groups of organisms—cytotoxin-producing, noninvasive bacteria (e.g. enteroaggregative Escherichia coli , enterohemorrhagic Escherichia coli and Clostridium difficile ), or by invasive organisms (e.g. Salmonella spp., Shigella spp., Campylobacter spp., Entamoeba histolytica). The cytotoxin-producing organisms adhere to the mucosa, activate cytokines and stimulate the intestinal mucosa to release inflammatory mediators. Invasive organisms, which can also produce cytotoxins, invade the intestinal mucosa to induce an acute inflammatory reaction, involving the activation of cytokines and inflammatory mediators. Regardless of the underlying mechanism they use, these various types of pathogen have all successfully evolved to evade and modulate the host defense systems. The mechanisms by which the different pathogens invade the host and cause infectious diarrhea are the topic of this Review.

Infectious diarrhea is a global health problem and can be classified, based on the pathogenesis and clinical presentation, as noninflammatory diarrhea or inflammatory diarrhea

Various host factors protect against enteric infection, and enteropathogens must overcome these to cause disease

Common microbial causes of noninflammatory diarrhea are viruses, enterotoxin-producing organisms, Giardia lamblia and Cryptosporidium parvum

Enterotoxigenic Escherichia coli and Vibrio cholerae infections cause ADP ribosylation of G s protein, whereas heat-stable enterotoxin-producing E. coli stimulate cGMP production; both E. coli and V. cholerae increase chloride secretion by crypt cells to produce watery diarrhea

Inflammatory diarrhea is caused by two groups of organisms: cytotoxin-producing, noninvasive bacteria (enteroaggregative E. coli , enterohemorrhagic E. coli , and Clostridium difficile ); and invasive organisms (e.g. Salmonella spp., Shigella spp., Campylobacter jejuni )

Cytotoxin-producing organisms adhere to the mucosa, activate cytokines and stimulate the intestinal mucosa to release inflammatory mediators; invasive organisms, which can also secrete cytotoxins, invade the intestinal mucosa to induce an acute inflammatory reaction and activate cytokines and inflammatory mediators

This is a preview of subscription content, access via your institution

Access options

Subscribe to this journal

Receive 12 print issues and online access

195,33 € per year

only 16,28 € per issue

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF

Prices may be subject to local taxes which are calculated during checkout

literature review of diarrhea

Similar content being viewed by others

literature review of diarrhea

Impact of enteric bacterial infections at and beyond the epithelial barrier

literature review of diarrhea

Salmonella Typhimurium and inflammation: a pathogen-centric affair

literature review of diarrhea

Enterotoxigenic Escherichia coli heat-labile toxin drives enteropathic changes in small intestinal epithelia

Kosek M et al . (2003) The global burden of diarrheal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 81 : 197–204

PubMed   PubMed Central   Google Scholar  

WHO (2005) Cholera, 2004. Wkly Epidemiol Rec 80 : 261–268

WHO (2001) Assainissement et diarrhée. Agir contre les infections 2 : 1–2

Garthright WE et al . (1988) Estimates of incidence and costs of intestinal infectious diseases in the United States. Public Health Rep 103 : 107–115

CAS   PubMed   PubMed Central   Google Scholar  

Steffen R (2005) Epidemiology of traveler's diarrhea. Clin Infect Dis 41 : S536–S540

PubMed   Google Scholar  

Gaea S and Fasano A (2005) Current concepts in the evaluation, diagnosis and management of acute infectious diarrhea. Curr Opin Pharmacol 5 : 559–565

Google Scholar  

Thielman NM and Guerrant RL (2004) Clinical practice. Acute infectious diarrhea. N Engl J Med 350 : 38–47

CAS   PubMed   Google Scholar  

Giannella RA (2006) Infectious enteritis and proctocolitis and food poisoning. In. Sleisenger & Fordtran's Gastrointestinal and Liver Disease , edn 8 2333–2391 (Ed. Feldman M) Philadelphia: WB Saunders

Giannella RA et al . (1972) Gastric acid barrier to ingested microorganisms in man: In vivo and in vitro studies. Gut 13 : 251–256

Musher DM and Musher BL (2004) Contagious acute gastrointestinal infections. N Eng J Med 351 : 2417–2428

CAS   Google Scholar  

Rodriguez WJ et al . (1987) Longitudinal study of rotavirus infection and gastroenteritis in families served by a pediatric medical practice: clinical and epidemiologic observations. Pediatr Infect Dis J 6 : 170–176

Ciarlet M and Estes MK (2001) Rotavirus and calicivirus infections of the GI tract. Curr Opin Gastroenterol 17 : 10–16

WHO (2000) Cholera, 1999. Wkly Epidemiol Rec 75 : 249

Morris JG and Black RE (1985) Cholera and other vibrios in the United States. N Engl J Med 312 : 343–350

Ramamurthy T et al . (1993) Emergence of novel strain of Vibrio cholerae with epidemic potential in southern and eastern India. Lancet 341 : 703–704

Cholera Working Group (1993) Large epidemic of cholera-like disease in Bangladesh caused by Vibrio cholerae 0139 synonym Bengal. Lancet 342 : 387–390

Levine MM et al . (1993) Epidemiologic studies of Escherichia coli diarrheal infections in a low socioeconomic level peri-urban community in Santiago, Chile. Am J Epidemiol 138 : 849–869

Taylor DN et al . (1988) Clinical and microbiologic features of Shigella and enteroinvasive Escherichia coli infections detected by DNA hybridization. J Clin Microbiol 26 : 1362–1366

Slutsker L et al . (1997) Escherichia coli O157:H7 diarrhea in the United States: clinical and epidemiological features. Ann Intern Med 126 : 505–513

Nataro J et al . (2006) Diarrheagenic E. coli in Baltimore, Maryland and New Haven, Connecticut. Clin Infect Dis 43 : 402–407

Huang DB et al . (2004) Enteroaggregative Escherichia coli : an emerging enteric pathogen. Am J Gastroenterol 99 : 383–389

Keusch GT (2002) Shigella and enteroinvasive E. coli In Infections of the GI Tract , edn 2 643–667 (Eds Blaser M. et al .) Philadelphia: Lippincott Williams & Wilkins

Altekruse SF et al . (1999) Campylobacter jejuni : an emerging food borne pathogen. Emerg Infect Dis 5 : 28–35

Kyne L et al . (2001) Clostridium difficile . Gastroenterol Clin North Am 3 : 753–777

McFarland LV (1995) Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients. Am J Infect Control 23 : 295–305

Haque R et al . (2003) Amebiasis. N Engl J Med 348 : 1565–1573

Faubert GM et al . (2002) Giardia duodenalis . In Infections of the GI Tract , edn 2 979–1006 (Eds Blaser M. et al .) Philadelphia: Lippincott Williams & Wilkins

Current WL et al . (1983) Human cryptosporidiosis in immunocompetent and immunodeficient persons: studies of an outbreak and experimental transmission. N Engl J Med 308 : 1252–1257

Evans CA et al . (1997) Gastric acid secretion and enteric infection in Bangladesh. Trans R Soc Trop Med Hyg 91 : 681–685

Hornick RB et al . (1971) The Broad Street pump revisited: response of volunteers to ingested cholera vibrios. Bull NY Acad Med 47 : 1181–1191

Gibbons RJ (1982) Review and discussion of role of mucus in mucosal defense. In Recent Advances in Mucosal Immunity , 342–352 (Eds Strober W. et al .) New York: Raven

Dinari G et al . (1986) Effect of guinea pig or monkey colonic mucus on Shigella aggregation and invasion of HeLa cells by Shigella flexneri lb and 2a. Infec Immun 51 : 975–978

Justus PG et al . (1982) Myoelectrical effects of C. difficile : motility-altering factor distinct from its cytotoxin and enterotoxin in rabbits. Gastroenterology 83 : 836–843

Hentges DJ (1967) Influence of pH on the inhibitory activity of formic and acetic acids fo. Shigella. J Bacteriol 93 : 2029–2030

Bohnhoff M and Miller CP (1962) Enhancing susceptibility to Salmonella infection in streptomycin-treated mice. J Infect Dis 111 : 117–127

Rabbani GH et al . (1999) Short-chain fatty acids improve clinical, pathologic, and microbiologic features of experimental shigellosis. J Infect Dis 179 : 390–397

Elson CO and Mestecky JF (2002) The mucosal immune system. In Infections of the GI Tract , edn 2 127–139 (Eds Blaser M. et al .) Philadelphia: Lippincott Williams & Wilkins

Freter R (1969) Intestinal immunity: studies of the mechanism of action of intestinal immunity in experimental cholera. Tex Rep Biol Med 27 : 299

Donnelly MA and Steiner TS (2002) Two non adjacent regions in enteroaggregative Escherichia coli flagellin are required for activation of toll like receptor 5. J Biol Chem 277 : 40456–40461

Lehrer RI et al . (1993) Defensins: antimicrobial and cytotoxic peptides of mammalian cells. Annu Rev Immunol 11 : 105–128

Wehkamp J et al . (2005) Mechanisms of Disease: defensins in gastrointestinal diseases. Nat Clin Pract Gastroenterol Hepatol 2 : 406–415

Hanson LA et al . (1985) Defense of mucosal membranes by antibodies, receptor analogues, and non-specific host factors. Infection 13 : S166–S170

Jiang ZD et al . (2003) Genetic susceptibility to enteroaggregative Escherichia coli diarrhea—polymorphism in the interleukin 8 promoter region. J Infect Dis 188 : 506–511

Jiang ZD et al . (2006) A common polymorphism in the interleukin 8 gene promoter is associated with Clostridium difficile diarrhea. Am J Gastroenterol. 101 : 1112–1116

Mohamed JA et al . (2007) A novel single-nucleotide polymorphism in the lactoferrin gene is associated with susceptibility to diarrhea in North American travelers to Mexico. Clin Infect Dis 44 : 945–952

Lindesmith L et al . (2003) Human susceptibility and resistance to Norwalk virus infection. Nat Med 9 : 548–553

Kirkpatrick BD et al . (2008) Association between Cryptosporidium infection and human leukocyte antigen class I and class II alleles. J Infect Dis 197 : 474–478

Duggal P et al . (2007) The study of associations betwee. Entamoeba histolytica infection and disease with single nucleotide polymorphisms (SNPS) in immune response genes . Presented at the American Society of Tropical Medicine and Hygiene (ASTMH) 56th Annual Meeting: 2007 November 4–8, Philadelphia, PA

Duggal P et al . (2004) Influence of human leukocyte antigen class II alleles on susceptibility to Entamoeba histolytica infection in Bangladeshi children. J Infect Dis 189 : 520–526

Williams-Blangero S et al . (2008) Localization of multiple quantitative trait loci influencing susceptibility to infection with Ascaris lumbricoides . J Infect Dis 197 : 66–71

Peisong G et al . (2004) An asthma-associated genetic variant of STAT6 predicts low burden of ascaris worm infestation. Genes Immun 5 : 58–62

Oria RB et al . (2007) Role of apolipoprotein E4 in protecting children against early childhood diarrhea outcomes and implications for later development. Med Hypotheses 68 : 1099–1107

Dhar U et al . (1996) Clinical features, antimicrobial susceptibility and toxin production in Vibrio cholerae O139 infection: comparison with V. cholerae O1 infection. Trans R Soc Trop Med Hyg 90 : 402–405

Basu A et al . (2000) Vibrio cholerae 0139 in Calcutta, 1992–1998: incidence, antibiograms, and genotypes. Emerg Infect Dis 6 : 139

Sack DA et al . (2004) Cholera. Lancet 363 : 223–233

Sánchez J and Holmgren J (2005) Virulence factors, pathogenesis and vaccine protection in cholera and ETEC diarrhea. Curr Opin Immunol 17 : 388–398

Shogomori H and Futerman AH (2001) Cholera toxin is found in detergent insoluble rafts/domains at the cell surface of hippocampal neurons but is internalized via a raft-independent mechanism. J Biol Chem 276 : 9182–9188

Massol RH et al . (2004) Cholera toxin toxicity does not require functional Arf6- and dynamin-dependent endocytic pathways. Mol Biol Cell 15 : 3631–3641

Mourad FH et al . (1995) Role of 5-hydroxytryptamine type 3 receptors in rat intestinal fluid and electrolyte secretion induced by cholera and Escherichia coli enterotoxins. Gut 37 : 340–345

Evans DG et al . (1975) Plasmid-controlled colonization factor associated with virulence in Escherichia coli enterotoxigenic for humans. Infect Immun 12 : 656–667

Moss J and Richardson SH (1978) Activation of adenylate cyclase by heat-labile E. coli enterotoxin. J Clin Invest 62 : 281–285

Karlsson KA et al . (1996) Unexpected carbohydrate cross-binding by Escherichia coli heat-labile enterotoxin. Recognition of human and rabbit target cell glycoconjugates in comparison with cholera toxin. Bioorg Med Chem 4 : 1919–1928

Wolf MK (1997) Occurrence, distribution, and associations of O and H serogroups, colonization factor antigens, and toxins of enterotoxigenic Escherichia coli . Clin Microbiol Rev 10 : 569–584

Lundgren O and Svensson L (2001) Pathogenesis of Rotavirus diarrhea. Microbes Infect 3 : 1145–1156

Halaihel N et al . (2000) Rotavirus infection impairs intestinal brush-border membrane Na (+) solute co transport activities in young rabbits. Am J Physiol Gastrointest Liver Physiol 279 : G587–G596

Langer RC et al . (2001) Characterization of an intestinal epithelial cell receptor recognized by the Cryptosporidium parvum sporozoite ligand CSL. Infect Immun 69 : 1661–1670

Simon D et al . (1994) Studies on the pathogenesis of cryptosporidia-incuced diarrhea in HIV-infected individuals. Am J Gastroenterol 89 : 2277–2278

Guarino A et al . (1995). Human intestinal cryptosporidiosis: secretory diarrhea and enterotoxic activity in Caco-2 cells. J Infect Dis 171 : 976–983

Genta RM et al . (1993) Duodenal morphology and intensity of infection in AIDS-related intestinal cryptosporidiosis. Gastroenterology 105 : 1769–1775

Hill DR (1990) Giardia lamblia . In: Principles and Practice of Infectious Diseases 2487–2493 (Eds Mandell GL. et al .) Philadelphia: Churchill Livingstone

Oberhuber G et al . (1997) Giardiasis: a histologic analysis of 567 cases. Scand J Gastroenterol 32 : 48–51

Berni Canani R et al . (2006) Inhibitory effect of HIV-1 Tat protein on the sodium-D-glucose symporter of human intestinal epithelial cells. AIDS 20 : 5–10

Griffin PM et al . (2002) Escherichia coli O157:H7 and other enterohemorrhagic E. coli . In Infections of the GI Tract , edn 2 627–642 (Eds Blaser M. et al .) Philadelphia: Lippincott Williams & Wilkins

Su C and Brandt LJ (1995) Escherichia coli O157:H7 infection in humans. Ann Intern Med 123 : 698–714

Warny M and Kelly CP (2003) Pathogenicity of Clostridium difficile toxins. I. Microbial Pathogenesis and the Intestinal Epithelial Cell , 503 (Ed. Hecht G) Washington, DC: ASM Press

Riegler M et al . (1995) Clostridium difficile toxin B is more potent than toxin A in damaging human colonic epithelium in vitro . J Clin Invest 95 : 2004–2011

Wilkins TD and Tucker KD (1989) C. difficile toxin A uses gal-α1–3galβ1–4GlcNAC as a functional receptor. Microecol Ther 19 : 225–231

Nataro JP and Kaper JB (1998) Diarrheaegenic E. coli . Clin Microbiol Rev 11 : 142–201

Okeke IN et al . (2000) Heterogeneous virulence of enteroaggregative Escherichia coli strains isolated from children in Southwest Nigeria. J Infect Dis 181 : 252–260

Sheikh J et al . (2002) A novel dispersin protein in enteroaggregative Escherichia coli . J Clin Invest 110 : 1329–1337

Vial PA et al . (1988) Characterization of enteroadherent-aggregative Escherichia coli , a putative agent of diarrheal disease. J Infect Dis 158 : 70–79

Weintraub A (2007) Enteroaggregative E. coli : epidemiology, virulence, and detection. J Med Microbiol 56 : 4–8

Phalipon A and Sansonetti PJ (2003) Shigellosis: innate mechanisms of inflammatory destruction of the intestinal epithelium, adaptive immune response, and vaccine development. Crit Rev Immunol 23 : 371–401

Fleckenstein JM and Kopecko DJ (2001) Breaching the mucosal barrier by stealth: an emerging pathogenic mechanism for enteroadherent bacterial pathogens. J Clin Invest 107 : 27–30

Matkowskyj KA et al . (2000) Galanin-1 receptor up-regulation mediates the excess colonic fluid production caused by infection with enteric pathogens. Nat Med 6 : 1048–1051

Grassl GA and Finlay BB (2008) Pathogenesis of enteric Salmonella infections. Curr Opin Gastroenterol 24 : 22–26

Oelschlaeger TA et al . (1993) Unusual microtubule-dependent endocytosis mechanisms triggered by Campylobacter jejuni and Citrobacter freundii . Proc Natl Acad Sci USA 90 : 6884–6888

Hu L and Kopecko DJ (2000) Interactions of Campylobacter with eukaryotic cells: gut luminal colonization and mucosal invasion mechanisms. In Campylobacter , edn 2 191–205 (Eds Nachamkin I and Blaser MJ) Washington, DC: ASM Press

Hickey TE et al . (2000) Campylobacter jejuni cytolethal distending toxin mediates release of interleukin-8 from intestinal epithelial cells. Infect Immun 68 : 6535–6541

Ravdin JI and Guerrant RL (1981) Role of adherence in cytopathogenic mechanisms of Entamoeba histolytica : study with mammalian tissue culture cells and human erythrocytes. J Clin Invest 68 : 1305–1313

Moncada D et al . (2003) Entamoeba histolytica cysteine proteinases disrupt the polymeric structure of colonic mucin and alter its protective function. Infect Immun 71 : 838–844

Download references

Author information

Authors and affiliations.

U Navaneethan is a Resident in the Department of Internal Medicine, and RA Giannella is the Mark Brown Professor of Medicine in the Division of Digestive Diseases, at the University of Cincinnati College of Medicine, Cincinnati, OH, USA.,

Udayakumar Navaneethan & Ralph A Giannella

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Ralph A Giannella .

Ethics declarations

Competing interests.

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Navaneethan, U., Giannella, R. Mechanisms of infectious diarrhea. Nat Rev Gastroenterol Hepatol 5 , 637–647 (2008). https://doi.org/10.1038/ncpgasthep1264

Download citation

Received : 27 March 2008

Accepted : 20 August 2008

Published : 23 September 2008

Issue Date : November 2008

DOI : https://doi.org/10.1038/ncpgasthep1264

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Promising clinical and immunological efficacy of bacillus clausii spore probiotics for supportive treatment of persistent diarrhea in children.

  • Ha Thuy Dang
  • Dien Minh Tran
  • Anh Thi Van Nguyen

Scientific Reports (2024)

Associations between long-term drought and diarrhea among children under five in low- and middle-income countries

  • Ernest Asare

Nature Communications (2022)

Meteorological and social conditions contribute to infectious diarrhea in China

  • Weifeng Xiong

Scientific Reports (2021)

Temperature and risk of infectious diarrhea: a systematic review and meta-analysis

  • Mingming Liang
  • Xiuxiu Ding

Environmental Science and Pollution Research (2021)

Gut microbiota signature of pathogen-dependent dysbiosis in viral gastroenteritis

  • Taketoshi Mizutani
  • Samuel Yaw Aboagye
  • Hiroshi Kiyono

Quick links

  • Explore articles by subject
  • Guide to authors
  • Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

literature review of diarrhea

Disclaimer » Advertising

  • HealthyChildren.org

Issue Cover

  • Next Article

Practice Gaps

Introduction, definitions, etiology of diarrheal illness, viral gastroenteritis, bacterial gastroenteritis, salmonella species, shigella species, campylobacter jejuni, diarrheagenic escherichia coli, clostridium difficile, special populations, noninfectious diarrhea, persistent diarrhea, diagnostic considerations, evaluation of acute diarrhea, assessment of dehydration, diagnostic evaluation, prevention and treatment, vaccinations, rehydration, management of hospitalized patients with age, antiemetic medication, antimotility agents, probiotics and prebiotics, zinc supplementation, update on diarrhea.

AUTHOR DISCLOSURE

Drs CaJacob and Cohen have disclosed no financial relationships relevant to this article. This commentary does not contain discussion of an unapproved/investigative use of a commercial product/device.

  • Split-Screen
  • Article contents
  • Figures & tables
  • Supplementary Data
  • Peer Review
  • CME Quiz Close Quiz
  • Open the PDF for in another window
  • Get Permissions
  • Cite Icon Cite
  • Search Site

Nicholas J. CaJacob , Mitchell B. Cohen; Update on Diarrhea. Pediatr Rev August 2016; 37 (8): 313–322. https://doi.org/10.1542/pir.2015-0099

Download citation file:

  • Ris (Zotero)
  • Reference Manager

The mainstay of management of infectious diarrheal illness in children remains supportive care with oral or intravenous rehydration. In the postvaccine era, norovirus has supplanted rotavirus as the leading cause of gastroenteritis presenting to medical facilities in the United States.

After reading this article, the reader should be able to:

Recognize the common pathogens associated with infectious diarrhea and develop a management plan.

Identify the key differences between infectious and noninfectious causes of diarrhea.

Effectively treat a child with cow milk protein intolerance.

Recognize that antidiarrheal and antimotility agents are not indicated or recommended in the treatment of infectious diarrhea.

Understand the changing epidemiology of infectious diarrhea in the postvaccine era.

Diarrhea is a worldwide problem that is frequently encountered in the practice of pediatric medicine. According to the World Health Organization, diarrheal illness is the second leading cause of death in children younger than age 5 years, accounting for 760,000 deaths per year in this age group. ( 1 )

The overwhelming majority of diarrheal illnesses are due to acute infectious diarrhea, commonly referred to as acute gastroenteritis (AGE). The degree of dehydration, assessed by both history and physical examination, is the most important indicator of disease severity. However, most children who have infectious diarrhea are not dehydrated and can be successfully treated at home with replacement of ongoing fluid losses using oral rehydration solution (ORS).

The routine use of antibiotics and antidiarrheal agents is not recommended for treatment of acute diarrhea and may cause harm. Restrictive diets are not necessary; the adverse effects on nutritional status during diarrheal illness can be lessened or prevented by rapid reinstitution of a regular feeding regimen, which most often can include milk and milk products. ( 2 )( 3 )

In this article, we provide an update on the diagnosis and clinical management of diarrheal illness for the general clinician.

Stools that are more frequent or looser in consistency than an individual’s regular stools are generally regarded as diarrhea. Stools may contain blood, mucus, fat, or undigested food particles. Parents frequently are anxious about differences in stool color, but only red (blood), black, tarry (melena, upper gastrointestinal bleeding), or white (acholic) stools are generally alarming.

Classifying diarrhea based on timing and content is clinically more useful. Categorization helps guide evaluation and management decisions. Four clinical classifications exist for diarrheal conditions:

Acute watery diarrhea lasting several hours to days

Acute bloody diarrhea or dysentery

Prolonged diarrhea lasting 7 to 14 days and persistent diarrhea lasting 14 days or longer

Diarrhea with severe malnutrition, which places the child at high risk for complications

Acute watery diarrhea is generally viral- or toxin-mediated. Replacement of ongoing fluid losses and reassurance usually are all that is required. Because the illness is typically self-limited, regardless of the etiologic microorganism, no specific testing is indicated.

Acute bloody diarrhea is an urgent issue that requires quick action. This is in contradistinction to blood in a nondiarrheal stool, which, in an otherwise well-appearing infant or child, is more likely to be associated with a less urgent problem such as a fissure, milk protein intolerance, or polyp. Blood in a diarrheal stool is a sign of infection, allergic reaction, or immune-mediated inflammation, as seen in inflammatory bowel disease. At a minimum, the presentation of acute bloody diarrhea necessitates collection of a stool sample for culture. This allows identification and proper management of potentially life-threatening illnesses such as hemolytic-uremic syndrome (HUS) caused by Escherichia coli O157:H7.

Diarrhea that persists longer than 14 days may be infectious, may represent the unmasking of a chronic illness, or may be a complication of AGE. Giardia and Cryptosporidium species are the most common enteric protozoan infections that cause persistent diarrhea. Clostridium difficile infection should also be considered when diarrhea is persistent. Chronic illnesses that may present as acute and persistent diarrhea include celiac disease and inflammatory bowel disease. Diarrhea-predominant irritable bowel syndrome can present as a complication of postinfectious diarrhea in adults. The equivalent illness in children may be chronic nonspecific diarrhea (CNSD). In children, another cause of postinfectious persistent diarrhea is villous atrophy related to mucosal injury by an infectious agent or an allergen. Historically, this illness was associated with enteropathogenic E coli infection. Villous atrophy appears to have decreased in frequency with the disappearance of this infection in many developed countries and with the use of age-appropriate regular diets either during the acute or prolonged phase of illness. Reinstitution of feeding is believed to aid in mucosal healing and recovery of the absorptive potential of the intestine. ( 4 )

Diarrhea in the setting of severe malnutrition, especially vitamin A deficiency and zinc deficiency, is deserving of its own category due to the increased risk of severe complications and even death. This scenario is rarely encountered in developed nations, but it remains a problem in many parts of the world. Global health efforts to reduce this category of diarrheal illness have the potential to drastically decrease mortality and morbidity in children worldwide.

Although most diarrheal illness is due to viral, bacterial, or parasitic infections, the noninfectious causes of childhood diarrhea are important for clinicians to consider and differentiate from infectious causes. ( 5 ) Of particular importance are the noninfectious causes in the very young infant (<30 days of age) or where diarrhea is prolonged or persistent.

The most common viral pathogens encountered in the United States are norovirus and rotavirus. Viral infections typically cause low-grade fevers and watery nonbloody diarrhea.

Recent publications indicate that norovirus has overtaken rotavirus as the leading cause of medical visits related to viral gastroenteritis in the United States, with an estimated 1 million health care visits annually. ( 6 ) Norovirus is the leading cause of foodborne disease outbreaks and is frequently implicated in traveler’s diarrhea. Typically, infections with norovirus result in a less severe gastroenteritis than infections with rotavirus and are characterized by frequent vomiting. Due to antigenic diversity, norovirus infection does not lead to lasting host immunity in subsequent seasons when another variant emerges.

Rotavirus is a key pathogen in global childhood morbidity and mortality related to diarrheal illness. The burden of disease is especially high in developing countries, where poor sanitation and close living quarters contribute to the spread of this highly infectious disease. Very few infectious virions are required to cause disease in a susceptible host. Before widespread vaccination in the United States beginning in 2006, nearly every child was infected with rotavirus by age 5 years. ( 7 ) Rotavirus infections tend to cluster in the winter months in temperate climates, while more tropical climates have less specific seasonality. Infections with rotavirus generally are more severe and protracted than infections that have other causes, leading to more severe dehydration. Rotavirus was the cause of 20% to 50% of severe AGE cases in young children worldwide. In areas where vaccine implementation has been successful, rotavirus-related hospitalizations and death have declined dramatically. This success is somewhat less pronounced in developing countries. ( 8 )

Although less common than viral causes, bacterial infections are an important cause of acute diarrheal disease in children. Certain clinical findings, including high temperature (>40°C [104°F]), bloody stools, severe abdominal pain, and central nervous system involvement, suggest a bacterial pathogen; vomiting and respiratory symptoms are more consistent with viral causes. ( 2 )

Salmonella species are commonly implicated in bacterial gastroenteritis worldwide. Children infected with nontyphoidal Salmonella species typically have a mild, self-limited gastroenteritis characterized by watery, bloody, or nonbloody diarrhea; vomiting; and fever. Extraintestinal complications are common in children younger than age 3 months, including bacteremia, meningitis, and osteomyelitis. Diagnosis is confirmed on stool culture . Treatment with antibiotics is reserved for special populations, including those at high risk of disseminated disease (age younger than 3 months, immunocompromised patients, and those with sickle cell disease) and those with suspected or proven sepsis or who appear toxic. Recommended treatment regimens are based on local resistance patterns, culture susceptibility data, patient age, and risk of extraintestinal complications. Antimicrobials with activity against Salmonella species include ampicillin/amoxicillin, trimethoprim-sulfamethoxazole, tetracyclines, third-generation cephalosporins, macrolides, and fluoroquinolones. The optimal duration of treatment for Salmonella gastroenteritis has not been defined, but expert opinions call for a 5- to 7-day course.

Shigella species are the most common cause of bloody diarrhea in children. Only 10 to 100 organisms are required for person-to-person transmission via the fecal-oral route. Children infected with Shigella species generally present with fever, malaise, watery diarrhea, tenesmus, and crampy abdominal pain. Blood and mucus are typically present in the stools by the second day of illness. Routine stool culture can differentiate this organism from other invasive pathogens. The infection usually is self-limited, resolving in 48 to 72 hours after symptom onset. Treatment with antibiotics is reserved for those who are severely ill or hospitalized. Antimicrobial resistance to first-line agents is common in Shigella infections. Accordingly, antimicrobial selection should be guided by local resistance patterns and culture susceptibility data. Strains susceptible to ampicillin or trimethoprim-sulfamethoxazole can be treated for 5 days. Infection control measures, including strict handwashing, should be implemented in outbreaks at schools and child care facilities, where infections may spread quickly. The high temperature often seen at the onset of illness has been associated with febrile seizures.

Bacterial gastroenteritis caused by Campylobacter jejuni is common worldwide. In developed countries, infection follows a bimodal pattern, with peaks in children younger than age 2 years and again in young adults. The illness can range in severity from mild diarrhea to frank dysentery. Fever, malaise, nausea, and abdominal pain are common. Stool culture is the gold standard for diagnosis. Most children recover in 1 week without specific antimicrobial treatment. Treatment is reserved for severe disease and for outbreaks in child care settings. The primary benefit of treatment is the reduction of fecal shedding from 2 weeks to 48 hours. The recommended treatment regimen is a 5-day course of erythromycin.

Escherichia coli are both part of the normal human large intestinal microbiota and important pathogens associated with diarrheal illnesses worldwide. Diarrheagenic strains of E coli have virulence factors that produce distinct clinical presentations. Of particular clinical importance is E coli O157:H7 infection, which presents with bloody diarrhea and can lead to HUS in up to 20% of affected individuals. ( 9 ) Experts recommend that children infected with E coli O157:H7 or other shiga-like toxin producing E coli , be hospitalized for volume expansion with intravenous (IV) fluids. By hospitalizing such children for careful monitoring, clinicians can judiciously hydrate patients, avoid unintentional harm resulting from antibiotic or antimotility medication, and minimize secondary spread. Patients with confirmed E coli O157:H7 are highly infectious, and infection control is more easily achieved in the hospital. IV volume expansion with fluids appears to protect the kidneys. Careful monitoring of urine output is critical to avoid fluid overload in patients at risk for HUS. The goal of volume expansion is to avoid the anuric phase of HUS because this portends a worse prognosis. Most experts agree not to treat children with E coli O157:H7 with antimicrobials due to concern that this increases the risk of developing HUS.

Clostridium difficile is an increasingly prevalent cause of diarrhea in both hospitalized and nonhospitalized children. Historically, C difficile infection was believed to affect only high-risk populations following exposure to antibiotics. Community-acquired C difficile infection rates have increased over the past decade, now accounting for about 25% of all C difficile infections. Although exposure to antibiotics remains a risk factor, it is no longer considered requisite in the pathogenesis of C difficile infection. ( 10 ) In addition, although C difficile diarrhea in children was classically described as bloody, it may be nonbloody.

Discontinuation of antimicrobial agents is often the first step in treating C difficile infection and may suffice when appropriate. For patients not receiving concurrent antimicrobial agents and for those with moderate or severe disease, proper empiric antibiotic treatment should be started as soon as the diagnosis is suspected. The initial treatment recommendation is a course of oral metronidazole for 10 to 14 days. Recurrent C difficile infection in children is increasing and often presents a treatment challenge. A repeated course of oral metronidazole is recommended for primary relapse; a course of oral vancomycin is recommended for subsequent relapse. Prolonged therapy and pulse therapy have also been used to treat recurrent disease. The use of fecal microbiota transplant (FMT) in treatment of refractory C difficile infection in children and adults is gaining widespread acceptance, although its long-term safety is uncertain. The US Food and Drug Administration (FDA) recently approved FMT as a treatment for recurrent C difficile infection. Additional evidence suggests that probiotics and prebiotics can decrease the severity and duration of C difficile infection. ( 11 )

Children who are immunodeficient, malnourished, or have an underlying chronic medical condition are at higher risk for a more severe and prolonged disease course with common diarrheal pathogens. Opportunistic microorganisms such as Cytomegalovirus species can also cause persistent and severe diarrhea in these populations.

Noninfectious causes of diarrhea represent a broad range of disease states ( Table 1 ). A few general principles are helpful in differentiating the relatively uncommon noninfectious causes of diarrheal diseases from infectious causes. Onset of diarrhea at birth or in children younger than age 30 days is concerning for a congenital diarrheal disorder and warrants prompt evaluation by a subspecialist.

Noninfectious Causes of Diarrhea in Children

Reproduced from J Pediatr Gastroenterol Nutr. 2014;59(1):132–152.

Food protein–induced proctocolitis (“cow milk protein intolerance”), a nonimmunoglobulin E-mediated process, usually presents in the first postnatal month in otherwise healthy infants who have blood-streaked stools. Diarrhea is notably absent in this condition. Up to 60% of cases occur in exclusively breastfed infants. Cow milk protein intolerance is primarily a clinical diagnosis. A complete blood cell count can be useful because most infants have normal-to-borderline low hemoglobin values. Additional laboratory testing, including assessing peripheral eosinophilia and the presence of fecal leukocytes, is limited by poor specificity. Symptoms typically resolve within 1 to 3 weeks after the elimination of milk- and soy-containing products in the maternal diet in breastfed infants or transition to a partially hydrolyzed formula. A trial of soy-based formula can be attempted, but up to 40% of infants react to both cow milk and soy proteins. Reintroduction of milk- and soy-containing products may be attempted as early as age 6 months, and most individuals achieve clinical tolerance by age 1 year. ( 12 ) The long-term prognosis is excellent, with no increased incidence of (immunoglobin) IgE-mediated allergies to milk or soy proteins.

Most acute diarrheal episodes resolve in less than 1 week; prolonged diarrhea that lasts for 7 to 14 days is a risk factor for development of persistent diarrhea. Persistent diarrhea in children has an age-related spectrum of disease. In infants and young children, the typical causes include persistent intestinal infections, intractable diarrhea of infancy (postinfectious diarrhea), intolerance to specific nutrients such as cow milk protein (allergic colitis) or dietary carbohydrates (sucrose and lactose), pancreatic insufficiency, and chronic nonspecific diarrhea (CNSD or toddler’s diarrhea).

Celiac disease is an important cause of persistent diarrhea throughout childhood, and inflammatory bowel disease is a consideration, especially when there is bloody diarrhea, poor growth, or other extraintestinal manifestations. ( 4 ) Food allergy is often suggested as a cause for persistent diarrhea. When food allergy is the cause, diarrhea occurs most commonly in immediate relationship to the ingested food in question, and there are other manifestations of allergy, including hives or wheezing. Eosinophilic gastroenteritis may be a cause of diarrheal disease and requires endoscopy and biopsy for diagnosis.

According to the Rome III criteria, CNSD is defined as toddler’s diarrhea in children younger than age 4 years and as irritable bowel syndrome in children ages 5 to 18 years. ( 13 ) Children with CNSD do not have evidence of weight loss or blood in the stool, and they maintain a normal appetite and activity level. The diarrhea in CNSD only occurs during the waking hours. Typically, affected children have a large formed or semiformed stool upon awakening and have frequent smaller, watery stools as the day progresses.

A stepwise approach to the evaluation and treatment of children with persistent diarrhea is necessary. History and the child’s age are among the most important guides.

In a child who is not gaining weight, evaluation for persistent infections, celiac disease, intractable diarrhea of infancy, pancreatic insufficiency, and inflammatory bowel disease is indicated. For example, preliminary evaluation might include bacterial stool culture, testing for C difficile , evaluation for parasites with direct fluorescent antigen, inflammatory markers (complete blood cell count, erythrocyte sedimentation rate, fecal calprotectin), specific serologic tests for celiac disease (tissue transglutaminase-IgA or antiendomysial antibodies-IgA), or fecal elastase.

Diarrhea in a child who is otherwise well and gaining weight is more likely to be due to functional causes or dietary intolerance. Most adults and many older children and adolescents develop relative lactase deficiency, also known as primary lactase deficiency, due to age-related declines in the intestinal enzyme lactase. The rate of primary lactase deficiency is higher in patients of Asian (80% to 100%) or African (70% to 95%) descent than those from Europe (15% to 70%). ( 14 ) Transient lactase deficiency following AGE is common in infants. Persistent lactase deficiency is exceedingly rare in infants and is overdiagnosed. Sucrase (sucrose-isomaltase) deficiency is less common following AGE but is a rare cause of persistent diarrhea in children. The diagnosis of dietary carbohydrate intolerance can be established with a trial of avoidance (eg, lactose-free diet) or treatment (eg, lactase-treated milk, hydrogen breath testing, or intestinal biopsy).

Infectious diarrheal illness is typically a mild, self-limiting disease process that can be successfully treated at home. Uncomplicated cases of AGE can be managed via telephone consultation, with a focus on obtaining sufficient information to evaluate the child’s clinical condition and risk for dehydration. ( 2 )

Infants and toddlers should be referred for medical evaluation if any of the following is present:

Moderate-to-severe illness in a child younger than 3 months (eg, fever, irritability, or abdominal distention)

Severe underlying disease such as diabetes or renal failure, which increases the risk for complications

Persistent vomiting

High-output diarrhea with large stool volumes (>8 episodes per day) or reported signs of severe dehydration

Accurate assessment of the degree of dehydration in children with AGE serves as a basis for management decisions. Dehydration in AGE occurs due to the increased loss of water and electrolytes (principally sodium, chloride, potassium, and bicarbonate) in the diarrheal stool with inadequate replacement. The ideal method of assessing fluid losses is to compare the pre-illness bodyweight to the current weight to calculate the percentage of weight loss. Real-world application of this method is limited, and clinicians typically rely on a global assessment: e.g., skin turgor, sunken eyes, general appearance, capillary refill time and mucous membranes, or a validated scoring tool to assist them in the assessment of dehydration in children. The Clinical Dehydration Scale is an easy-to-use and well-validated tool in the assessment of dehydration ( Table 2 ). There are 3 generally accepted categories of dehydration severity: 1) no or minimal dehydration, 2) mild-to-moderate dehydration, and 3) severe dehydration.

Clinical Dehydration Scale (CDS) for Children

A score of 0 represents no dehydration, a score of 1 to 4 represents some dehydration, and a score of 5 to 8 represents moderate/severe dehydration.

Laboratory tests are not recommended in the routine assessment of dehydration. The results of testing in the setting of mild-to-moderate dehydration may distract the clinician from signs and symptoms that have proven diagnostic utility. Recent evidence suggests that urinary indices, including specific gravity and the presence of ketones, are not useful in the assessment of dehydration. However, electrolytes should be measured in all hospitalized patients who have severe dehydration and in children requiring IV rehydration therapy to assess hyper- or hyponatremia. It is important to remember that the early stages of dehydration are asymptomatic, and early initiation of fluid replacement is critical in the prevention of worsening dehydration.

Episodes of AGE in children do not generally require a specific diagnostic evaluation. Microbiologic investigation is not indicated in most cases of AGE because most pathogens do not require treatment with a specific antimicrobial agent. Investigation is warranted for outbreaks in child care, school, or hospital settings; children who have bloody diarrhea (dysentery); or for patients who have underlying chronic illness or immunodeficiency.

Routine microscopic stool examination for polymorphonuclear cells is of limited clinical utility because a large number of children with gastroenteritis have a negative test result (<5 polymorphonuclear cells per high-powered field).

There are currently 2 licensed rotavirus vaccines in the United States, Rotarix ® (GSK, Middlesex, United Kingdom) and RotaTeq ® (Merck Sharp & Dohme Corp, Kenilworth, NJ). Since the introduction of rotavirus vaccine in the United States in 2006, diarrhea-associated health care use and medical expenditures have declined substantially. ( 7 ) From 2007 to 2009, there was an estimated reduction of 64,855 hospitalizations related to diarrheal illness associated with an approximately $278 million decrease in treatment costs. More recent studies have found even greater reductions, which have been attributed to herd immunity.

Oral and Enteral Rehydration.

Oral rehydration and replacement of ongoing fluid losses with reduced-osmolarity (50-60 mmol/L sodium) ORS has replaced isotonic ORS as the first-line treatment for children with AGE. Recent studies have shown that reduced-osmolarity ORS is more effective than full-strength ORS, resulting in reduced stool output, reduced vomiting, and reduced need for supplemental IV therapy. The oral route is preferred, but when this is not feasible, enteral instillation via nasogastric (NG) tube is a secondary option. The use of oral and/or enteral rehydration is safer, reduces hospital stay, and is equally successful compared to IV rehydration in most children. ( 2 )

The worldwide reduction of morbidity and mortality associated with AGE following the introduction of ORS is one of the true success stories of the past 50 years. ORS has become the cornerstone of therapy in the management of acute diarrheal illnesses worldwide.

Parenteral Rehydration.

The use of IV rehydration should be limited to select circumstances, including:

Dehydration with altered level of consciousness or severe acidosis

Worsening of dehydration or lack of improvement despite oral or enteral rehydration therapy

Persistent vomiting that compromises oral or NG tube hydration

Severe abdominal distention and ileus

Children presenting with shock due to AGE need rapid IV infusion of crystalloid solution as a 20-mL/kg bolus, followed by repeated boluses as needed, based on clinical response. Glucose-containing replacement fluids should be initiated in the maintenance phase of IV rehydration. Once the clinical condition permits, a switch to oral hydration is appropriate.

The two pillars of management in AGE are immediate attempts at oral rehydration and rapid reintroduction of regular feeding following initial fluid rehydration (generally within 4-6 hours). There is no difference in episodes of vomiting, diarrhea, or need for unscheduled IV fluids in patients with early versus late refeeding in the setting of AGE.

Breastfeeding should not be interrupted during episodes of AGE. Active breastfeeding may be associated with a reduced incidence of AGE. Most formula-fed infants can also resume a lactose-based diet once dehydration has been treated. Exceptions to this are infants who have severe diarrhea or diarrhea requiring hospitalization. In addition, if the infant is very young (<3 months old) or follow-up evaluation cannot be assured, a temporary switch to a nonlactose formula is appropriate.

No standardized admission criteria exist for children with AGE. Based on consensus guidelines, indications for hospitalization include the following:

Severe dehydration (>9% of body weight)

Neurologic abnormalities (eg, lethargy, seizures)

Intractable or bilious vomiting

Failure of oral rehydration

Concern for a surgical abdomen

Inability to ensure that the caregivers or conditions at home will provide adequate monitoring, follow-up evaluation, or return to the hospital if needed

Contact precautions are indicated in addition to standard precautions in hospitalized children with AGE. Efforts to decrease the hospital length of stay in children with AGE are aimed at reducing the duration of symptoms and completing the transition to oral replacement of ongoing diarrheal losses.

The routine use of antiemetics in the treatment of AGE in children is controversial. Such use is not indicated for children younger than age 3 years. However, ondansetron therapy has been shown to decrease the risk for persistent vomiting, the need for IV fluids, and the risk of immediate hospital admission in children with vomiting related to AGE. ( 2 ) Prescribers should be aware that increased diarrhea frequency is one of the most common adverse effects of ondansetron. Safety considerations must also be taken into account, considering the FDA’s “black box” alert recommending electrocardiographic monitoring in patients with electrolyte abnormalities who are receiving ondansetron because they may be at risk for developing prolongation of the QT interval that can lead to an abnormal and potentially fatal ventricular tachydysrhythmia. ( 2 )

Antimotility agents, such as loperamide, are usually contraindicated in the treatment of childhood AGE. Although the risk for harm is based on only a few reports of toxic megacolon or ileus, there is minimal evidence of benefit in children. There is a much stronger case for potential harm with other opioids, especially those that cross the blood-brain barrier, including “third spacing of fluids in the intestine,” and minimal benefit. Therefore, most guidelines state that antimotility agents are not indicated in children with AGE, especially those younger than age 3 years.

Probiotics are live microorganisms that are believed to work by stimulating the host immune system and competing for binding sites on intestinal epithelial cells. The use of probiotics in children with acute and persistent diarrhea is associated with reduced severity and duration of illness. ( 15 )( 16 ) The effect is modest, with an average decrease of 1 day of diarrheal illness. Controversy surrounds the routine use of probiotics in acute diarrheal illness, but they seem to be most effective when started early in the disease course in otherwise healthy individuals with viral gastroenteritis.

Prebiotics are oligosaccharides that stimulate the growth of commensal intestinal flora. Trials of these agents have failed to show a significant decrease in diarrheal severity or length of illness in children and, therefore, they are not routinely recommended.

The role of zinc supplementation in children with AGE is well established for developing countries where malnutrition is a significant risk factor.

On the basis of recent epidemiologic evidence, norovirus has supplanted rotavirus as the most common cause of infectious diarrhea in the postvaccine era in the United States.

On the basis of some research evidence as well as consensus, infants with milk protein-induced proctocolitis (“cow milk protein intolerance”) may attempt reintroduction of milk- and soy protein-containing products as early as age 6 months.

On the basis of strong evidence, using a validated tool to assess and classify the severity of dehydration in children with acute diarrheal illness is recommended to guide management decisions.

On the basis of strong evidence, rapid initiation of oral rehydration with oral rehydration solution is the preferred method for replacing fluid and electrolyte losses in the setting of acute gastroenteritis.

On the basis of strong evidence, reintroduction of regular age-appropriate feedings, including milk, after initial fluid resuscitation is the standard of care for acute diarrheal illnesses.

On the basis of some research evidence as well as consensus, ondansetron therapy in select patients with vomiting related to acute gastroenteritis may be effective, but safety in children remains to be established.

Competing Interests

Advertising Disclaimer »

Citing articles via

Email alerts.

literature review of diarrhea

Affiliations

  • Editorial Board
  • ABP Content Spec Map
  • Pediatrics On Call
  • Online ISSN 1526-3347
  • Print ISSN 0191-9601
  • Pediatrics Open Science
  • Hospital Pediatrics
  • Pediatrics in Review
  • AAP Grand Rounds
  • Latest News
  • Pediatric Care Online
  • Red Book Online
  • Pediatric Patient Education
  • AAP Toolkits
  • AAP Pediatric Coding Newsletter

First 1,000 Days Knowledge Center

Institutions/librarians, group practices, licensing/permissions, integrations, advertising.

  • Privacy Statement | Accessibility Statement | Terms of Use | Support Center | Contact Us
  • © Copyright American Academy of Pediatrics

This Feature Is Available To Subscribers Only

Sign In or Create an Account

Advertisement

Advertisement

A Review on Prevention Interventions to Decrease Diarrheal Diseases’ Burden in Children

  • Pediatric Global Health (D Nguyen and A Mandalakas, Section Editors)
  • Published: 22 March 2018
  • Volume 5 , pages 31–40, ( 2018 )

Cite this article

literature review of diarrhea

  • Camille Webb 1 &
  • Miguel M. Cabada 1 , 2  

8111 Accesses

11 Citations

Explore all metrics

Purpose of Review

Provide an overview about childhood diarrhea burden and prevention interventions with demonstrated impact in reducing disease risk.

Recent Findings

Diarrhea incidence and mortality in children is declining around the world. A few pathogens cause most of the burden (rotavirus, norovirus, Shigella , enterotoxigenic E. coli , Campylobacter , and Cryptosporidium ). Available rotavirus vaccines have demonstrated to significantly decrease diarrhea hospital admissions and mortality. WASH interventions, especially point of use water safety improvements and handwashing, are effective in decreasing diarrhea burden. Early and exclusive breastfeeding prevents early childhood diarrhea.

Diarrhea in children under 5 years old is still among the most important causes of mortality in middle- and low-income countries. However, diarrhea complications and deaths are preventable. Vaccines, water, sanitation, and hygiene (WASH) and breastfeeding are effective and affordable interventions. Future research should determine the effectiveness of combining these interventions and address problems in implementation and integration of interventions.

Similar content being viewed by others

literature review of diarrhea

Exclusive breastfeeding and rotavirus vaccination are associated with decreased diarrheal morbidity among under-five children in Bahir Dar, northwest Ethiopia

literature review of diarrhea

Rotavirus and other diarrheal disease in a birth cohort from Southern Indian community

Water, sanitation and hygiene interventions for acute childhood diarrhea: a systematic review to provide estimates for the lives saved tool.

Avoid common mistakes on your manuscript.

Introduction

Diarrhea is among the most common morbidities affecting children under 5 years old with an estimated 960 million cases worldwide in 2015. Diarrhea mortality rate has declined 39% between 2005 and 2015, but it still is the fourth leading cause of death in this age group, responsible for killing half a million children [ 1 ••]. More than 70% of these deaths occur in children 2 years of age and younger [ 2 ]. These figures are estimates of deaths in which diarrhea was the primary cause identified. However, as suggested by Ahmed et al. in a verbal autopsy study in Bangladesh, diarrhea may contribute to children mortality as a secondary cause which may make its impact even larger [ 3 ]. Low- and middle-income countries disproportionately bear the burden of diarrheal diseases. It is estimated that in 2015, diarrhea caused over 71 million DALYs of which 45 million were among children under 5 years old and 99% of these occurred in low- and middle-income countries [ 1 ••]. The African, South Asian, and South East Asian regions have the highest burden of diarrhea in the world [ 4 ] (Fig.  1 ).

Percentage of deaths attributable to diarrheal diseases among children under 5 years old in 2015. Modified with permission. Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE) provisional estimates 2015, as presented in UNICEF’s report: One is too many: Ending child deaths from pneumonia and diarrhea. ISBN: 978-92-806-4859-1

Children that survive diarrhea are confronted with long-term consequences that include malnutrition and developmental delays. A recent episode of diarrhea was associated with underweight, stunting, and wasting in a Burkina Faso study among children under 5 years [ 5 ]. A vicious cycle ensues where diarrheal diseases predispose children to malnutrition, and this in turn makes them more vulnerable to severe diarrhea and diarrhea-related mortality [ 6 , 7 ]. In a recent birth cohort study by Haworth EJN et al., Nepali children exposed to diarrhea at an early age were 2.5 times more likely to have a disability 10 years later than children without early diarrhea [ 8 ]. Diarrhea early in life may have an independent effect on cognitive function that is not necessarily mediated by the effects on nutritional status [ 9 ]. Thus, diarrhea hinders children developing to their full potential and may affect future productivity and quality of life. In addition to these effects on the individual, diarrhea imposes a large burden on household and health system economics in low-income countries further perpetuating poverty [ 10 ]. As reported by Ngabo et al., the hospitalization of a child with diarrhea can cost as much as the family’s income for the entire month [ 11 ].

Acute diarrhea is caused by more than 20 different viral, bacterial, and parasitic pathogens. However, recent studies have provided insight about the entero-pathogens responsible for the highest burden and their differences in age and geographic distribution. According to the Global Enteric Multicenter Study (GEMS) conducted in Africa and Asia among children under 5 years old seeking medical care, the most common pathogens causing moderate to severe diarrhea were rotavirus, Cryptosporidium, enterotoxigenic E. coli producing heat stable toxin, and Shigella [ 12 •]. In this study, heat-stable toxin producing enterotoxigenic E. coli and enteropathogenic E. coli were associated with increased mortality in children younger than 12 months, and Cryptosporidium was associated with increased mortality in children between 12 and 23 months old [ 12 •]. In contrast, the Multisite Birth Cohort Study (MAL-ED), a community-based birth cohort that conducted intensive surveillance of diarrhea in South America, Africa, and Asia, showed that norovirus, rotavirus, Campylobacter, astrovirus, and Cryptosporidium cause the highest burden on children younger than 12 months. In the same study, Campylobacter, norovirus, rotavirus, astrovirus, and Shigella caused most of the cases of diarrhea among children 12 to 23 months of age [ 13 ••]. Overall, rotavirus, Shigella, adenovirus, and Cryptosporidium were associated with more severe diarrhea [ 13 ••]. Smaller studies in China, Senegal, and Turkey showed similar results and confirmed the notion that interventions directed to control a limited number of pathogens are likely to have a large impact on diarrhea incidence and mortality [ 14 , 15 , 16 ]. In addition, the emergence of multidrug-resistant bacterial enteropathogens in low-income countries underscores the need for effective prevention strategies for diarrheal diseases [ 17 ]. A recent study from Bihar in India showed high levels of resistance to penicillins, cephalosporins, and quinolones, including extended spectrum beta-lactamase producing enterotoxigenic E. coli , enteropathogenic E. coli , and enteroaggregative E. coli [ 18 ].

Lack of access to clean water and hygiene, poor sanitation, malnutrition, and non-exclusive breastfeeding are important risk factor for diarrhea in children. Pathogen-specific characteristics like virulence and infectivity also play an important role in diarrhea epidemiology [ 19 ]. Several interventions focusing on specific risk factors and pathogens have produced an estimated reduction of diarrhea incidence of 10.4% and diarrheal deaths of 20.8% in recent years [ 1 ••]. Most importantly, some of these approaches have shown that child mortality associated with diarrhea is preventable. In this manuscript, we will review interventions used to prevent diarrhea among children and their impact or potential to cause significant declines in disease burden.

The development of vaccines directed against enteropathogens causing the highest burden of diarrhea will likely achieve a large reduction in morbidity and mortality. A few of these vaccines are already commercially available and several others are under investigation (extensively reviewed in 20 ••, 21 ••). Several rotavirus and Vibrio cholerae vaccines are internationally available and endorsed by the World Health Organization for disease control. Norovirus and Shigella vaccine candidates are in advanced clinical development stages [ 20 ••, 21 ••].

Rotavirus Vaccines

In low-income countries, 80% of children are infected with rotavirus at least once before reaching 1 year of age [ 22 ]. Rotavirus diarrhea is associated with moderate to severe disease and death. In the MAL-ED cohort, almost 5% of diarrhea episodes in the community among children younger than 2 years old were attributed to rotavirus infection [ 13 ••]. However, between 10 and 27% of moderate to severe diarrhea episodes were attributed to rotavirus among children of the same age in the GEMS study, which included children with more severe diarrhea [ 12 •]. In 2013, an estimated 37% of the diarrhea-associated deaths were caused by rotavirus [ 23 ]. Thus, vaccines that prevent rotavirus moderate to severe diarrhea and mortality have a large impact. Several rotavirus vaccines are currently offered commercially, but only two, Rotarix (GlaxoSmithKline Biologicals) and Rotateq (Merck & Company), have been extensively studied and are pre-qualified by the World Health Organization (WHO) [ 20 ] (Table  1 ). The effectiveness of these vaccines is similar and varies according to the region and local risk for diarrhea [ 24 , 30 , 31 ].

The introduction of Rotarix and Rotateq vaccines is associated with significant reductions in rotavirus hospitalizations and diarrhea mortality. A systematic review of observational studies on the impact of rotavirus vaccine program implementation showed an overall 38% reduction in hospitalizations and 42% reduction in mortality due to acute gastroenteritis among children under 5 years of age. In the same age group, the reduction in rotavirus related hospitalizations was reduced 80% [ 32 ]. In Botswana, vaccine coverages between 76 and 90% in children up to 2 years old achieved reductions in gastroenteritis-related hospitalizations and deaths of 23 and 22%, respectively [ 33 ]. Armah et al. reported a reduction of hospital admissions between 28 and 48% among the first 3 years of vaccine introduction in Ghana [ 34 ]. Shah et al. estimated that 134,714 hospitalizations and 20,986 deaths were prevented in 2016 after the introduction of rotavirus vaccination in 33 African countries [ 35 ]. In addition, rotavirus vaccination is associated with significant cost prevention for the healthcare system in low- and high-income countries [ 36 , 37 ]. Given the evidence on effectiveness and cost savings, the WHO recommends introducing rotavirus vaccine in all national vaccination programs since 2013 [ 22 ].

Vibrio cholerae Vaccine

V. cholerae causes severe acute diarrhea leading to rapid dehydration. Cholera has a regional distribution closely related to poverty and lack of access to clean water and sanitation. Cholera is known to cause large outbreaks, but also occurs as an endemic illness mainly in countries of Africa and South Asia. The estimated numbers of annual cholera cases and associated deaths are 2.9 million and 95,000, respectively [ 38 ].

WHO emphasizes that WASH interventions are essential for cholera control, but it also recommends cholera vaccination as a complement in high-risk endemic areas and in outbreaks [ 39 ]. Three oral cholera vaccines are available and qualified by WHO: Dukoral (Valneva), Shanchol (Shantha Biotechnics), and Euvichol (Eubiologics) [ 40 ] (Table  2 ). Dukoral is recommended for ages 2 years and up and has an efficacy between 78 and 85% against cholera and may provide short-term cross-protection against enterotoxigenic E. coli [ 44 ]. The other two vaccines, Shanchol and Euvichol, are recommended for ages 1 year and up and have an efficacy between 40 and 87%. Except for Vaxchora, all cholera vaccines are given in two dose regimens with 2–6 weeks in between administrations. However, a recent systematic review and meta-analysis suggested that a single dose of oral cholera vaccine provides protection against cholera in 87% of subjects at 2 months and 33% at 3 years [ 45 ]. These data support single dose use in outbreaks where urgency and logistics for deployment may prevent the use of 2 dose regimens. Based on cost, production capacity, and implementation potential, Shanchol and Euvichol were chosen to create an oral cholera vaccine global stockpile in 2013. This stockpile has delivered more than 7 million doses of oral cholera vaccine in 14 countries for humanitarian emergencies and outbreaks [ 44 ].

WHO estimates that 88% of diarrheal diseases worldwide can be attributed to unsafe water, inadequate sanitation, and poor hygiene. In 2015, 844 million people lacked access to basic drinking water services (drinking water free of pathogens or chemicals within 30-min round trip time), and 159 million people were still collecting drinking water from surface sources. For the same period, 2.3 billion lacked basic sanitation, and 892 million people were still practicing open defecation. Almost half of the people living in low- and middle-income countries completely lacked handwashing facilities [ 46 ]. Thus, significant numbers of the world’s population have no access to water, sanitation, and hygiene (WASH), and their countries are facing challenges in implementation of education and infrastructure.

A recent Cochrane database review by Clasen et al. evaluated the impact of interventions to improve water quality on diarrhea. As compared with interventions to improve water safety at the source, interventions at the point of use showed significant benefits in diarrhea prevention. Household chlorination, flocculation, and solar disinfection decreased the risk of diarrhea by 23, 31, and 38%, respectively. Filtration, especially with Biosand systems, showed the highest impact in reducing diarrhea risk by 52% [ 47 •]. Filtration may be especially effective in preventing diarrhea by specific pathogen resistant to other interventions like Cryptosporidium [ 48 ].

Promotion of handwashing with soap and water decreases the risk of diarrhea by 25% [ 49 , 50 ]. However, rates of handwashing before eating and after using the toilet are low and inconsistent in low- and middle-income countries. A study in 51 countries evaluating availability of handwashing materials as proxy for handwashing behaviors showed that between 0 and 96% of the households had soap and water in their handwashing facilities. The availability of materials was significantly more common in wealthy countries and urban settings [ 51 ]. In a study by Pengpid and Peltzer, among adolescents from 9 African countries, only 62% reported washing hands consistently before eating, 58% after using the toilet, and 35% using soap [ 52 ]. A similar study in three countries of the Pacific Micronesia showed handwashing rates before eating and after toileting of 65 and 80% [ 53 ]. Educational interventions aimed at increasing handwashing before eating, after using the toilet, and using soap achieve improvements in behaviors when infrastructure is available and soap is provided [ 54 ]. Studies to support the effectiveness of educational interventions to increase handwashing among children are scarce and their results on diarrhea risk reduction are inconsistent [ 55 ]. Gover et al. reported on a different approach to changing handwashing behavior based on modifying the environment rather than focusing on education alone. Their study in Bangladesh showed that construction of handwashing facilities in schools including environmental “nudges” conducive to handwashing was as effective as high-intensity education to maintain the behavior among children 5 months after the intervention [ 56 ].

A recent meta-analysis evaluating WASH interventions and risk of diarrhea included only one study regarding the use of latrines and failed to show any effect [ 49 ]. In contrast, an older meta-analysis showed that 11 of the 13 studies evaluating different interventions to improve excreta disposal showed an effect on diarrhea risk. However, the heterogeneity between studies precluded the calculation of pooled effects [ 57 ]. Other studies have failed to show a difference in diarrhea risk in communities where improved sanitation interventions were implemented compared to those without them [ 58 , 59 ]. The variety of interventions aimed at improving excreta disposal and the inability to isolate their effects from other WASH interventions may explain the variability of the results.

The calculations of cost-benefit of combined sanitation and safe water interventions estimated an average ratio of dollar returned/dollar invested of 4.3 and a cost for universal access to water and sanitation of 35 billion dollars. In addition to the benefits in diarrhea prevention, improvements in safe water, hygiene, and sanitation access decrease soil-transmitted helminth infections and trachoma and improves nutrition in children adding to the cost-benefit estimations [ 60 , 61 , 62 ]. Data on combination of the most effective WASH intervention and the integration of these in existing health promotion programs is lacking. Implementation of interventions may find economic, political, and cultural barriers.

Breastfeeding

Breastfeeding has been recognized as a cost-effective strategy to reduce infant diarrhea worldwide. Several studies have documented the impact on reduction of diarrhea rates of early initiation of breastfeeding, exclusive breastfeeding, and duration of breastfeeding. However, rates of exclusive breastfeeding among children younger than 6 months in low- and middle-income countries are 37%, and only 63% receive any breast milk between ages 6 and 23 months [ 63 •]. A prospective study in Vietnam among 1049 6-month-old infants found that exclusive breastfeeding at 6 weeks of age significantly reduced the odds of inpatient admission for diarrheal illness (OR 0.37, 95% CI 0.15 to 0.88) [ 64 ]. Khan et al. reported that infants that interrupted exclusive breastfeeding before 6 months of age were between 2 and 5 times more likely to get diarrhea than infants that continued breastfeeding. In this study, the authors estimated that 27% of diarrhea episodes could have been prevented if exclusive breastfeeding would not have been interrupted [ 65 ]. A study in 9 sub-Saharan African countries with high diarrhea-associated mortality demonstrated that infants who initiated breastfeeding within the first hour of life and those who continued exclusive breastfeeding until 6 months of age were 20 and 50% less like to have diarrhea respectively after adjusting for demographic and socio-economic factors. These effects were maintained even after adjusting for differences in sanitation [ 66 ]. A review of Brazilian studies published in Portuguese and English languages showed that interventions aimed at promoting good breastfeeding practices (i.e., lactation centers) resulted in reductions of diarrhea rates and hospital admissions. Similarly to other studies, there were higher diarrhea rates and nutritional deficits among prematurely weaned infants [ 67 ]. Acharya et al. demonstrated that the diarrhea-protective effects of breastfeeding were annulled when other liquids or food was introduced among infants in Nepal. In this study, partial breastfeeding was associated with 3.5 times more diarrhea compared with exclusive breastfeeding [ 68 ]. In a meta-analysis of observational studies, Shen et al. were unable to demonstrate an independent association between breastfeeding and rotavirus infection. However, the studies were highly heterogeneous and showed significant differences in diarrhea risk and definitions of rotavirus diarrhea [ 69 ].

Some of the protective effects of breastfeeding are thought to be related to maternal antibodies present in breast milk. Human milk oligosaccharides influence infant microbiome, functioning as prebiotics to support growth of specific bacteria [ 70 ]. Breast milk contains dendritic cells, T cells, and plasma cells with gut-related phenotypes specific for maternal gut flora [ 63 •]. Exclusive breastfeeding prevents the ingestion of contaminated or improperly preserved beverages and food. Also, by avoiding the use of feeding bottles, it reduces the risk of cross-contamination of milk with unsafe water or improperly washed hands.

Victora et al. used an extensive compilation of systematic reviews to evaluate outcomes associated with breastfeeding. The authors estimated that scaling up exclusive breastfeeding in children under 6 months to 90% or more could prevent up to half of all diarrhea episodes and 72% of diarrhea-related admissions [ 63 •]. Breastfeeding rates over 90% are very ambitious considering that very few countries worldwide have a prevalence of breastfeeding over 85%. Implementation of high rates of breastfeeding will be challenging due to high variability in resources and local feeding culture even within countries. Barriers to exclusive breastfeeding include type and place of delivery, perceptions about breast milk, complications of breastfeeding, maternal employment or student status, and breastfeeding practice support in the household, community, and healthcare facilities [ 71 , 72 ]. Thus, educating mothers and the community on the importance and practice of breastfeeding and strengthening the health system to promote and support this practice may increase rates and have a broader impact on maternal and child health. Promotional interventions increase rates of breastfeeding. A review of 110 studies of breastfeeding interventions described a 43% increase in rates of exclusive breastfeeding at day 1 (RR 1.43, 95% CI 1.19–1.42), 30% at 1 month (RR 1.30, 95% CI 1.19–1.42), 90% at 6 months (RR 1.90, 95% CI 1.54–2.34), along with a decrease in rates of no breastfeeding. Individual and group counseling provided in healthcare facilities had the greatest impact on exclusive breastfeeding practices [ 73 ].

Several studies have linked malnutrition to an increased risk of diarrheal disease [ 74 , 75 ]. Malnutrition is also a consequence of repeated episodes of diarrhea. In addition to the enteric function and microbiota changes, inflammation, nutrient malabsorption induced by diarrhea [ 76 •], and the resistance from caregivers to continue feeding during diarrhea episodes increase the likelihood of malnutrition. A study on child-feeding practices including 390 caregivers in a peri-urban community of Lima in Peru showed that 73% of caregivers discontinued normal feeding during episodes of diarrhea and 40% withheld vegetables and fruits [ 77 ]. Continued feeding during episodes of diarrhea is associated with faster recovery of intestinal function and does not prolong duration of diarrhea. There is an opportunity for educational interventions targeting feeding practices during episodes of diarrhea.

Zinc is currently included in the WHO essential medicine list for diarrhea treatment and has been shown to be an effective component of diarrhea control. Zinc deficiency has been proposed to increase susceptibility to diarrhea due to this element’s role in regulation of intestinal fluid transportation and mucosal integrity as well as its role in the immune system [ 78 ]. A randomized clinical trial in 379 children younger than 5 years old in Iran showed lower frequency of diarrhea (4.5 vs 5.3 stools per day, P  = 0.004) in the group receiving zinc compared to the group receiving standard of care. This study also showed shorter duration of hospital stay in the group receiving zinc supplementation [ 79 ]. In Cairo, Eskander et al. studied 80 children aged 2 to 30 months admitted with diarrhea. Zinc deficiency (levels less than 60 μg/dl) was present in 56% of cases of diarrhea, and low levels of zinc correlated with dehydration and duration of hospital stay [ 80 ]. Similarly, a study on 354 children with diarrhea in India showed that median serum zinc levels were significantly lower in children with dehydration than those without dehydration (69.64 vs 82.86, p  < 0.001) [ 81 ]. A Cochrane systematic review which included 33 trials and 10,841 children showed that zinc supplementation could be of benefit in areas where the prevalence of zinc deficiency or malnutrition is high. However, the data did not support routine administration of zinc in children less than 6 months of age.

Children in low-resource countries are at increased risk of vitamin A deficiency, which affects approximately 190 million under 5 years old [ 82 ]. The prevalence of Vitamin A deficiency remains high in South Asia and sub-Saharan Africa [ 83 ]. Vitamin A supplementation has been studied in children with the intent to improve immune function and mortality associated with diarrhea as well as other infectious diseases. A Cochrane database review found that Vitamin A supplementation to children under 5 years of age was associated with a 15% reduction in diarrhea risk (RR 0.85, 95% CI 0.82 to 0.87) and 12% reduction in diarrhea mortality ((RR 0.88, 95% CI 0.79 to 0.98) [ 84 ].

Iron deficiency anemia is the most common nutrient deficiency worldwide, and iron supplementation and fortification is widely recommended in infants at risk of iron deficiency anemia. It is well documented that infants with iron deficiency anemia are at risk of poor cognitive, motor, and physiologic development. At the same time, several studies have reported an increased risk of infant diarrhea with iron supplementation. Iron-containing supplements can increase pathogen abundance, increase gut inflammation, and increase risk of diarrhea in infants receiving supplementation [ 85 , 86 •]. This leads to a complex relationship between nutrition, iron deficiency anemia, and risk of infection. Long-term studies on the risks and benefits of iron supplementation are needed.

There is little data to support routine use of probiotics in infant diarrhea. A recent review of evidence noted decreased duration of diarrhea by 1 day with no changes in stool output, with the most significant evidence for prevention of antibiotic associated diarrhea, (decrease from 23 to 9.6%, RR 0.48, 0.26 to 0.89) and no evidence to support that probiotics use decreases risk of infection [ 87 ].

Conclusions

Childhood diarrhea remains an urgent health priority and a leading cause of morbidity and mortality worldwide. While there have been significant advances in this field, lower income countries and lower income populations within countries remain disproportionately affected. Vaccine development and implementation, particularly of rotavirus, exclusive breastfeeding, and widespread efforts in improvement of sanitation and education have been shown to be successful strategies in prevention of childhood diarrhea. Further research should be directed at reductions of inequalities in implementing these practices and should evaluate the effectiveness of combining interventions for the prevention of diarrhea.

Papers of particular interest, published recently, have been highlighted as: • Of importance•• Of major importance

•• GBD Diarrhoeal Diseases Collaborators. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis. 2017;17(9):909–48. https://doi.org/10.1016/S1473-3099(17)30276-1 . The authors of this manuscript estimate the global burden of diarrhea and provide figures on mortality according to age, sex, and geographic location. Estimates of the burden caused by different etiologies are provided as well as the impact of prevention interventions .

Article   Google Scholar  

Das JK, Bhutta ZA. Global challenges in acute diarrhea. Curr Opin Gastroenterol. 2016;32(1):18–23. https://doi.org/10.1097/MOG.0000000000000236 .

Article   PubMed   Google Scholar  

Ahmed M, Abedin J, Alam KF, Al Mamun A, Paul RC, Rahman M, et al. Incidence of acute diarrhea-associated death among children < 5 years of age in Bangladesh, 2010-12. Am J Trop Med Hyg. 2017;98(1):281–6. https://doi.org/10.4269/ajtmh.17-0384 .

United Nation’s Children Fund. One is too many: ending child deaths from pneumonia and diarrhea [Online]. New York: Unicef; 2016 [cited 12/10/2017] Available from https://www.unicef.org/lac/20161111_UNICEF-one-is-too-many-report.pdf .

Poda GG, Hsu CY, Chao JC. Factors associated with malnutrition among children <5 years old in Burkina Faso: evidence from the Demographic and Health Surveys IV. Int J Qual Health Care. 2010;2017(7):1–8. https://doi.org/10.1093/intqhc/mzx129 .

Google Scholar  

Abera L, Dejene T, Laelago T. Prevalence of malnutrition and associated factors in children aged 6-59 months among rural dwellers of damot gale district, south Ethiopia: community based cross sectional study. Int J Equity Health. 2017;16(1):111. https://doi.org/10.1186/s12939-017-0608-9 .

Article   PubMed   PubMed Central   Google Scholar  

Tickell KD, Pavlinac PB, John-Stewart GC, Denno DM, Richardson BA, Naulikha JM, et al. Impact of childhood nutritional status on pathogen prevalence and severity of acute diarrhea. Am J Trop Med Hyg. 2017;97(5):1337–44. https://doi.org/10.4269/ajtmh.17-0139 .

Haworth EJN, Tumbahangphe KM, Costello A, Manandhar D, Adhikari D, Budhathoki B, et al. Prenatal and perinatal risk factors for disability in a rural Nepali birth cohort. BMJ Glob Health. 2017;2(3):e000312. https://doi.org/10.1136/bmjgh-2017-000312 .

Pinkerton R, Oria RB, Lima AA, Rogawski ET, Oria MO, Patrick PD, et al. Early childhood diarrhea predicts cognitive delays in later childhood independently of malnutrition. Am J Trop Med Hyg. 2016;95(5):1004–10. https://doi.org/10.4269/ajtmh.16-0150 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Giglio ND, Caruso M, Castellano VE, Choque L, Sandoval S, Micone P, et al. Hospitalization costs associated with diarrhea among children during the period of rotavirus circulation in the northwest region of Argentina. Arch Argent Pediatr. 2017;115(6):527–32. https://doi.org/10.5546/aap.2017.eng.527 .

PubMed   Google Scholar  

Ngabo F, Mvundura M, Gazley L, Gatera M, Rugambwa C, Kayonga E, et al. The economic burden attributable to a child's inpatient admission for diarrheal disease in Rwanda. PLoS One. 2016;11(2):e0149805. https://doi.org/10.1371/journal.pone.0149805 .

• Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet. 2013;382(9888):209–22. https://doi.org/10.1016/S0140-6736(13)60844-2 . Multicenter study evaluating the etiology and burden of moderate and severe diarrhea among children in African and Asian countries. This highlights the main causes on diarrhea and mortality in children under 2 years of age .

•• Platts-Mills JA, Babji S, Bodhidatta L, Gratz J, Haque R, Havt A, et al. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED). Lancet Glob Health. 2015;3(9):e564–75. https://doi.org/10.1016/S2214-109X(15)00151-5 . Multicenter birth cohort study in Latin America, Africa, and Asia evaluating the burden of diarrhea in the community and the main etiologic agent .

Li LL, Liu N, Humphries EM, Yu JM, Li S, Lindsay BR, et al. Aetiology of diarrhoeal disease and evaluation of viral-bacterial coinfection in children under 5 years old in China: a matched case-control study. Clin Microbiol Infect. 2016;22(4):381.e9–e16. https://doi.org/10.1016/j.cmi.2015.12.018 .

Article   CAS   Google Scholar  

Sire JM, Garin B, Chartier L, Fall NK, Tall A, Seck A, et al. Community-acquired infectious diarrhoea in children under 5 years of age in Dakar. Senegal Paediatr Int Child Health. 2013;33(3):139–44. https://doi.org/10.1179/2046905512Y.0000000046 .

Ozsari T, Bora G, Kaya B, Yakut K. The prevalence of rotavirus and adenovirus in the childhood gastroenteritis. Jundishapur J Microbiol. 2016;9(6):e34867. https://doi.org/10.5812/jjm.34867 .

Brander RL, Walson JL, John-Stewart GC, Naulikha JM, Ndonye J, Kipkemoi N, et al. Correlates of multi-drug non-susceptibility in enteric bacteria isolated from Kenyan children with acute diarrhea. PLoS Negl Trop Dis. 2017;11(10):e0005974. https://doi.org/10.1371/journal.pntd.0005974 .

Mandal A, Sengupta A, Kumar A, Singh UK, Jaiswal AK, Das P, et al. Molecular epidemiology of extended-spectrum beta-lactamase-producing Escherichia coli pathotypes in diarrheal children from low socioeconomic status communities in Bihar, India: emergence of the CTX-M type. Infect Dis (Auckl). 2017;10:1178633617739018. https://doi.org/10.1177/1178633617739018 .

Kotloff KL. The burden and etiology of diarrheal illness in developing countries. Pediatr Clin N Am. 2017;64(4):799–814. https://doi.org/10.1016/j.pcl.2017.03.006 .

•• O'Ryan M, Vidal R, del Canto F, Salazar JC, Montero D. Vaccines for viral and bacterial pathogens causing acute gastroenteritis: part I: overview, vaccines for enteric viruses and vibrio cholerae. Hum Vaccin Immunother. 2015;11(3):584–600. https://doi.org/10.1080/21645515.2015.1011019 . A comprehensive review of vaccines against viral and bacterial enteropathogens. The authors review the knowledge about already available vaccines against rotavirus and cholera. The review includes the progress made on vaccines for norovirus, Shigella , and other bacterium .

•• O'Ryan M, Vidal R, del Canto F, Carlos Salazar J, Montero D. Vaccines for viral and bacterial pathogens causing acute gastroenteritis: part II: vaccines for Shigella, Salmonella, enterotoxigenic E. coli (ETEC) enterohemorragic E. coli (EHEC) and Campylobacter jejuni. Hum Vaccin Immunother. 2015;11(3):601–19. https://doi.org/10.1080/21645515.2015.1011578 . A comprehensive review of vaccines against viral and bacterial enteropathogens. The authors review the knowledge about already available vaccines against rotavirus and cholera. The review includes the progress made on vaccines for norovirus, Shigella , and other bacterium .

WHO. Rotavirus vaccines. WHO position paper—January 2013. Wkly Epidemiol Rec. 2013;88(5):49–64.

Tate JE, Burton AH, Boschi-Pinto C, Parashar UD. Global, regional, and national estimates of rotavirus mortality in children <5 years of age, 2000-2013. Clin Infect Dis. 2016;62(Suppl 2):S96–s105. https://doi.org/10.1093/cid/civ1013 .

Soares-Weiser K, Maclehose H, Bergman H, Ben-Aharon I, Nagpal S, Goldberg E, et al. Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database Syst Rev. 2012;11:Cd008521. https://doi.org/10.1002/14651858.CD008521 .

Fu C, He Q, Xu J, Xie H, Ding P, Hu W, et al. Effectiveness of the Lanzhou lamb rotavirus vaccine against gastroenteritis among children. Vaccine. 2012;31(1):154–8. https://doi.org/10.1016/j.vaccine.2012.10.078 .

Article   CAS   PubMed   Google Scholar  

Dang DA, Nguyen VT, Vu DT, Nguyen TH, Nguyen DM, Yuhuan W, et al. A dose-escalation safety and immunogenicity study of a new live attenuated human rotavirus vaccine (Rotavin-M1) in Vietnamese children. Vaccine. 2012;30(Suppl 1):A114–21. https://doi.org/10.1016/j.vaccine.2011.07.118 .

Kulkarni PS, Desai S, Tewari T, Kawade A, Goyal N, Garg BS, et al. A randomized phase III clinical trial to assess the efficacy of a bovine-human reassortant pentavalent rotavirus vaccine in Indian infants. Vaccine. 2017;35(45):6228–37. https://doi.org/10.1016/j.vaccine.2017.09.014 .

Bhan MK, Glass RI, Ella KM, Bhandari N, Boslego J, Greenberg HB, et al. Team science and the creation of a novel rotavirus vaccine in India: a new framework for vaccine development. Lancet. 2014;383(9935):2180–3. https://doi.org/10.1016/S0140-6736(14)60191-4 .

Chandola TR, Taneja S, Goyal N, Antony K, Bhatia K, More D, et al. ROTAVAC((R)) does not interfere with the immune response to childhood vaccines in Indian infants: a randomized placebo controlled trial. Heliyon. 2017;3(5):e00302. https://doi.org/10.1016/j.heliyon.2017.e00302 .

Velazquez RF, Linhares AC, Munoz S, Seron P, Lorca P, DeAntonio R, et al. Efficacy, safety and effectiveness of licensed rotavirus vaccines: a systematic review and meta-analysis for Latin America and the Caribbean. BMC Pediatr. 2017;17(1):14. https://doi.org/10.1186/s12887-016-0771-y .

Lamberti LM, Ashraf S, Walker CL, Black RE. A systematic review of the effect of rotavirus vaccination on diarrhea outcomes among children younger than 5 years. Pediatr Infect Dis J. 2016;35(9):992–8. https://doi.org/10.1097/INF.0000000000001232 .

Burnett E, Jonesteller CL, Tate JE, Yen C, Parashar UD. Global impact of rotavirus vaccination on childhood hospitalizations and mortality from diarrhea. J Infect Dis. 2017;215(11):1666–72. https://doi.org/10.1093/infdis/jix186 .

Enane LA, Gastanaduy PA, Goldfarb DM, Pernica JM, Mokomane M, Moorad B, et al. Impact of rotavirus vaccination on hospitalizations and deaths from childhood gastroenteritis in Botswana. Clin Infect Dis. 2016;62(Suppl 2):S168–74. https://doi.org/10.1093/cid/civ1210 .

Armah G, Pringle K, Enweronu-Laryea CC, Ansong D, Mwenda JM, Diamenu SK, et al. Impact and effectiveness of monovalent rotavirus vaccine against severe rotavirus diarrhea in Ghana. Clin Infect Dis. 2016;62(Suppl 2):S200–7. https://doi.org/10.1093/cid/ciw014 .

Shah MP, Tate JE, Mwenda JM, Steele AD, Parashar UD. Estimated reductions in hospitalizations and deaths from childhood diarrhea following implementation of rotavirus vaccination in Africa. Expert Rev Vaccines. 2017;16(10):987–95. https://doi.org/10.1080/14760584.2017.1371595 .

Leino T, Baum U, Scott P, Ollgren J, Salo H. Impact of five years of rotavirus vaccination in Finland—and the associated cost savings in secondary healthcare. Vaccine. 2017;35(42):5611–7. https://doi.org/10.1016/j.vaccine.2017.08.052 .

Sarker AR, Sultana M, Mahumud RA, Van Der Meer R, Morton A. Cost-effectiveness analysis of introducing universal childhood rotavirus vaccination in Bangladesh. Hum Vaccin Immunotheer 2017:1–10. doi: https://doi.org/10.1080/21645515.2017.1356962 .

Ali M, Nelson AR, Lopez AL, Sack DA. Updated global burden of cholera in endemic countries. PLoS Negl Trop Dis. 2015;9(6):e0003832. https://doi.org/10.1371/journal.pntd.0003832 .

WHO. Cholera vaccines: WHO position paper—August 2017. Wkly Epidemiol Rec. 2017;92(34):477–98.

Walldorf JA, Date KA, Sreenivasan N, Harris JB, Hyde TB. Lessons learned from emergency response vaccination efforts for cholera, typhoid, yellow fever, and ebola. Emerg Infect Dis. 2017;23(13). doi: https://doi.org/10.3201/eid2313.170550 .

Charles RC, Hilaire IJ, Mayo-Smith LM, Teng JE, Jerome JG, Franke MF, et al. Immunogenicity of a killed bivalent (O1 and O139) whole cell oral cholera vaccine, Shanchol, in Haiti. PLoS Negl Trop Dis. 2014;8(5):e2828. https://doi.org/10.1371/journal.pntd.0002828 .

Baik YO, Choi SK, Olveda RM, Espos RA, Ligsay AD, Montellano MB, et al. A randomized, non-inferiority trial comparing two bivalent killed, whole cell, oral cholera vaccines (Euvichol vs Shanchol) in the Philippines. Vaccine. 2015;33(46):6360–5. https://doi.org/10.1016/j.vaccine.2015.08.075 .

Wong KK, Burdette E, Mahon BE, Mintz ED, Ryan ET, Reingold AL. Recommendations of the advisory committee on immunization practices for use of cholera vaccine. MMWR Morb Mortal Wkly Rep. 2017;66(18):482–5. https://doi.org/10.15585/mmwr.mm6618a6 .

SAGE Working Group on Oral Cholera Vaccines WS, The Centers for Disease Control and Prevention. Background paper on whole-cell, killed, oral cholera vaccines 2017 [Online] Global Task Force on Cholera Control (GTFCC) Oral Cholera Vaccine (OCV) Working Group. [cited 12/20/2017]. Available from: http://www.who.int/immunization/sage/meetings/2017/april/OCV_Background_Document_SageWG_FinalVersion_EditedPS_.pdf?ua=1 .

Lopez AL, Deen J, Azman AS, Luquero FJ, Kanungo S, Dutta S, et al. Immunogenicity and protection from a single dose of internationally available killed oral cholera vaccine: a systematic review and meta-analysis. Clin Infect Dis. 2017; https://doi.org/10.1093/cid/cix1039 .

UNICEF - WHOWatUNCsF. Progress on drinking water, sanitation and hygiene—update and SDG baselines 2017. Geneva: World Health Organization; 2017.

• Clasen TF, Alexander KT, Sinclair D, Boisson S, Peletz R, Chang HH, et al. Interventions to improve water quality for preventing diarrhoea. Cochrane Database Syst Rev 2015(10):Cd004794. doi: https://doi.org/10.1002/14651858.CD004794.pub3 . Metaanalysis of studies evaluating the impact of improvements in water quality and safety on diarrhea risk. The authors identified interventions at the point of use as the most effective. Among the interventions evaluated, sand biofilters appeared to have the largest effect .

Zambrano LD, Priest JW, Ivan E, Rusine J, Nagel C, Kirby M, et al. Use of serologic responses against enteropathogens to assess the impact of a point-of-use water filter: a randomized controlled trial in Western Province. Rwanda Am J Trop Med Hyg. 2017;97(3):876–87. https://doi.org/10.4269/ajtmh.16-1006 .

Darvesh 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(Suppl 4):776. https://doi.org/10.1186/s12889-017-4746-1 .

Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, et al. Hygiene and health: systematic review of hand washing practices worldwide and update of health effects. Tropical Med Int Health. 2014;19(8):906–16. https://doi.org/10.1111/tmi.12339 .

Kumar S, Loughnan L, Luyendijk R, Hernandez O, Weinger M, Arnold F, et al. Hand washing in 51 countries: analysis of proxy measures of hand washing behavior in multiple indicator cluster surveys and demographic and health surveys, 2010-2013. Am J Trop Med Hyg. 2017;97(2):447–59. https://doi.org/10.4269/ajtmh.16-0445 .

Pengpid S, Peltzer K. Hygiene behaviour and associated factors among in-school adolescents in nine African countries. Int J Behav Med. 2011;18(2):150–9. https://doi.org/10.1007/s12529-010-9109-6 .

Tran D, Phongsavan P, Bauman AE, Havea D, Galea G. Hygiene behaviour of adolescents in the Pacific: associations with socio-demographic, health behaviour and school environment. Asia Pac J Public Health. 2006;18(2):3–11. https://doi.org/10.1177/10105395060180020201 .

Bulled N, Poppe K, Ramatsisti K, Sitsula L, Winegar G, Gumbo J, et al. Assessing the environmental context of hand washing among school children in Limpopo. South Africa Water Int. 2017;42(5):568–84. https://doi.org/10.1080/02508060.2017.1335140 .

Watson JA, Ensink JHJ, Ramos M, Benelli P, Holdsworth E, Dreibelbis R, et al. Does targeting children with hygiene promotion messages work? The effect of handwashing promotion targeted at children, on diarrhoea, soil-transmitted helminth infections and behaviour change, in low- and middle-income countries. Tropical Med Int Health. 2017;22(5):526–38. https://doi.org/10.1111/tmi.12861 .

Grover E, Hossain MK, Uddin S, Venkatesh M, Ram PK, Dreibelbis R. Comparing the behavioural impact of a nudge-based handwashing intervention to high-intensity hygiene education: a cluster-randomised trial in rural Bangladesh. Tropical Med Int Health. 2017;23(1):10–25. https://doi.org/10.1111/tmi.12999 .

Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins MW, et al. Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database Syst Rev 2010;(6):Cd007180. doi: https://doi.org/10.1002/14651858.CD007180.pub2 .

Briceno B, Coville A, Gertler P, Martinez S. Are there synergies from combining hygiene and sanitation promotion campaigns: evidence from a large-scale cluster-randomized trial in rural Tanzania. PLoS One. 2017;12(11):e0186228. https://doi.org/10.1371/journal.pone.0186228 .

Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. Lancet Glob Health. 2015;3(11):e701–11. https://doi.org/10.1016/S2214-109X(15)00144-8 .

Tadesse B, Worku A, Kumie A, Yimer SA. Effect of water, sanitation and hygiene interventions on active trachoma in north and south Wollo zones of Amhara region, Ethiopia: a quasi-experimental study. PLoS Negl Trop Dis. 2017;11(11):e0006080. https://doi.org/10.1371/journal.pntd.0006080 .

Dangour AD, Watson L, Cumming O, Boisson S, Che Y, Velleman Y, et al. Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database Syst Rev 2013(8):Cd009382. doi: https://doi.org/10.1002/14651858.CD009382.pub2 .

Strunz EC, Addiss DG, Stocks ME, Ogden S, Utzinger J, Freeman MC. Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis. PLoS Med. 2014;11(3):e1001620. https://doi.org/10.1371/journal.pmed.1001620 .

• Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. https://doi.org/10.1016/S0140-6736(15)01024-7 . This metaanalysis evaluates the impact of breastfeeding on prevention of diarrhea and estimates the potential impact of widespread implementation of good breastfeeding practices .

Hanieh S, Ha TT, Simpson JA, Thuy TT, Khuong NC, Thoang DD, et al. Exclusive breast feeding in early infancy reduces the risk of inpatient admission for diarrhea and suspected pneumonia in rural Vietnam: a prospective cohort study. BMC Public Health. 2015;15(1):1166. https://doi.org/10.1186/s12889-015-2431-9 .

Khan MN, Islam MM. Effect of exclusive breastfeeding on selected adverse health and nutritional outcomes: a nationally representative study. BMC Public Health. 2017;17(1):889. https://doi.org/10.1186/s12889-017-4913-4 .

Ogbo FA, Agho K, Ogeleka P, Woolfenden S, Page A, Eastwood J. Infant feeding practices and diarrhoea in sub-Saharan African countries with high diarrhoea mortality. PLoS One. 2017;12(2):e0171792. https://doi.org/10.1371/journal.pone.0171792 .

Santos FS, Santos FC, Santos LH, Leite AM, Mello DF. Breastfeeding and protection against diarrhea: an integrative review of literature. Einstein (Sao Paulo). 2015;13(3):435–40. https://doi.org/10.1590/S1679-45082015RW3107 .

Acharya D, Singh JK, Adhikari M, Gautam S, Pandey P, Dayal V. Association of water handling and child feeding practice with childhood diarrhoea in rural community of southern Nepal. J Infect Public Health. 2017;11(1):69–74. https://doi.org/10.1016/j.jiph.2017.04.007 .

Shen J, Zhang BM, Zhu SG, Chen JJ. No direct correlation between rotavirus diarrhea and breast feeding: a meta-analysis. Pediatr Neonatol 2017. doi: https://doi.org/10.1016/j.pedneo.2017.06.002 .

Turin CG, Ochoa TJ. The role of maternal breast milk in preventing infantile diarrhea in the developing world. Curr Trop Med Rep. 2014;1(2):97–105. https://doi.org/10.1007/s40475-014-0015-x .

PubMed   PubMed Central   Google Scholar  

Mushaphi LF, Mahopo TC, Nesamvuni CN, Baloyi B, Mashau E, Richardson J, et al. Recommendations for infant feeding policy and programs in Dzimauli region, South Africa: results from the MAL-ED birth cohort. Food Nutr Bull. 2017;38(3):428–40. https://doi.org/10.1177/0379572117696662 .

Kavle JA, LaCroix E, Dau H, Engmann C. Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications. Public Health Nutr. 2017;20(17):3120–34. https://doi.org/10.1017/S1368980017002531 .

Haroon S, Das JK, Salam RA, Imdad A, Bhutta ZA. Breastfeeding promotion interventions and breastfeeding practices: a systematic review. BMC Public Health. 2013;13(Suppl 3):S20. https://doi.org/10.1186/1471-2458-13-S3-S20 .

Checkley W, Gilman RH, Black RE, Lescano AG, Cabrera L, Taylor DN, et al. Effects of nutritional status on diarrhea in Peruvian children. J Pediatr. 2002;140(2):210–8. https://doi.org/10.1067/mpd.2002.121820 .

Ferdous F, Das SK, Ahmed S, Farzana FD, Latham JR, Chisti MJ, et al. Severity of diarrhea and malnutrition among under five-year-old children in rural Bangladesh. Am J Trop Med Hyg. 2013;89(2):223–8. https://doi.org/10.4269/ajtmh.12-0743 .

• Prendergast AJ, Kelly P. Interactions between intestinal pathogens, enteropathy and malnutrition in developing countries. Curr Opin Infect Dis. 2016;29(3):229–36. https://doi.org/10.1097/QCO.0000000000000261 . This review evaluates the interactions between intestinal pathogens, malnutrition, and gastrointestinal diseases in developing countries .

Pantenburg B, Ochoa TJ, Ecker L, Ruiz J. Feeding of young children during diarrhea: caregivers’ intended practices and perceptions. Am J Trop Med Hyg. 2014;91(3):555–62. https://doi.org/10.4269/ajtmh.13-0235 .

Berni Canani R, Buccigrossi V, Passariello A. Mechanisms of action of zinc in acute diarrhea. Curr Opin Gastroenterol. 2011;27(1):8–12. https://doi.org/10.1097/MOG.0b013e32833fd48a .

Karamyyar M, Gheibi S, Noroozi M, Kord Valeshabad A. Therapeutic effects of oral zinc supplementation on acute watery diarrhea with moderate dehydration: a double-blind randomized clinical trial. Iran J Med Sci. 2013;38(2):93–9.

Eskander AE, Sherif LS, Nabih M, Baroudy NRE, Marcos GC, Badawy EA, et al. Serum zinc level and its correlation with Vesikari System Scoring in acute pediatric diarrhea. Open Access Maced J Med Sci. 2017;5(5):677–80. https://doi.org/10.3889/oamjms.2017.097 .

Agarwal A, Gupta NK, Upadhyay A, Soni RK, Shah D, Jaiswal V. Serum zinc levels as a predictor of severity of acute diarrhea. Indian J Pediatr. 2017; https://doi.org/10.1007/s12098-017-2493-z .

WHO. Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A deficiency Geneva: WHO Global Database on Vitamin A Deficiency; 2009 [cited 12/10/17] Available from: http://apps.who.int/iris/bitstream/10665/44110/1/9789241598019_eng.pdf .

Stevens GA, Bennett JE, Hennocq Q, Lu Y, De-Regil LM, Rogers L, et al. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. Lancet Glob Health. 2015;3(9):e528–36. https://doi.org/10.1016/S2214-109X(15)00039-X .

Imdad A, Mayo-Wilson E, Herzer K, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age. Cochrane Database Syst Rev. 2017;3:Cd008524. https://doi.org/10.1002/14651858.CD008524.pub3 .

Jaeggi T, Kortman GA, Moretti D, Chassard C, Holding P, Dostal A, et al. Iron fortification adversely affects the gut microbiome, increases pathogen abundance and induces intestinal inflammation in Kenyan infants. Gut. 2015;64(5):731–42. https://doi.org/10.1136/gutjnl-2014-307720 .

• Paganini D, Zimmermann MB. The effects of iron fortification and supplementation on the gut microbiome and diarrhea in infants and children: a review. Am J Clin Nutr. 2017;106(Suppl 6):1688s–93s. https://doi.org/10.3945/ajcn.117.156067 . Iron supplementation is widely recommended in low-income countries with high rates of malnutrition and of childhood diarrhea. This review looks at the potential interactions and effects of iron supplementation on childhood diarrhea .

Hojsak I. Probiotics in children: what is the evidence? Pediatr Gastroenterol Hepatol Nutr. 2017;20(3):139–46. https://doi.org/10.5223/pghn.2017.20.3.139 .

Download references

Author information

Authors and affiliations.

Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA

Camille Webb & Miguel M. Cabada

Universidad Peruana Cayetano Heredia and University of Texas Medical Branch Collaborative Research Center, Universidad Peruana Cayetano Heredia, Cusco, Peru

Miguel M. Cabada

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Miguel M. Cabada .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Pediatric Global Health

Rights and permissions

Reprints and permissions

About this article

Webb, C., Cabada, M.M. A Review on Prevention Interventions to Decrease Diarrheal Diseases’ Burden in Children. Curr Trop Med Rep 5 , 31–40 (2018). https://doi.org/10.1007/s40475-018-0134-x

Download citation

Published : 22 March 2018

Issue Date : March 2018

DOI : https://doi.org/10.1007/s40475-018-0134-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Find a journal
  • Publish with us
  • Track your research

Meta-analysis of the efficacy of probiotics to treat diarrhea

Affiliations.

  • 1 Nutritional Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
  • 2 Department of Critical Care Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
  • 3 Nutritional Department, Xuzhou Cancer Hospital, Xuzhou China.
  • PMID: 36197181
  • PMCID: PMC9509072
  • DOI: 10.1097/MD.0000000000030880

Background: To collect the published trials of probiotics in the treatment of diarrhea and to strictly evaluate and systematically analyze the efficacy of probiotics use for the prevention and treatment of patients with diarrhea.

Methods: We searched domestic and foreign literature published between January 2016 and July 2022 to find randomized control trials that used probiotics to treat diarrhea. Only studies published in English were considered. The quality of the included literatures was assessed by using the methods provided in the Cochrane Handbook. Valid data were extracted and analyzed by meta- analysis using the Software RevMan5.2.

Results: Total 16 trials and 1585 patients were included. The results of the meta- analysis showed that in comparison with the simple Western medicine treatment group or placebo, the added use of probiotics could improve stool frequency, stool morphology, and related irritable bowel syndrome symptoms.

Conclusion: The added use of probiotics can further improve clinical outcomes in the patients with diarrhea; however, the implementation of larger and higher quality clinical trials is necessary to verify this conclusion.

Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

Publication types

  • Meta-Analysis
  • Anti-Bacterial Agents / therapeutic use
  • Diarrhea / chemically induced
  • Irritable Bowel Syndrome* / drug therapy
  • Probiotics* / therapeutic use
  • Anti-Bacterial Agents
  • Open access
  • Published: 13 January 2022

The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: evidence from the global burden of disease study

  • Deepak Kumar Behera   ORCID: orcid.org/0000-0001-6539-4280 1 &
  • Sanghamitra Mishra   ORCID: orcid.org/0000-0002-5665-3380 2  

BMC Public Health volume  22 , Article number:  92 ( 2022 ) Cite this article

15k Accesses

27 Citations

7 Altmetric

Metrics details

This study aims to measure the burden of diarrhea in India and analyze the trend of mortality associated with it for the past 30 years. We also intend to find the prevailing etiology and risk factors associated with diarrheal mortality in India.

The study has used the latest round of Global Burden of Disease (GBD) study-2019. GBD data is available across age groups and gender-wise over the period from 1990 to 2019. The study has identified 13 etiologies for the cause of diarrhea deaths and 20 risk factors to analyze the burden of disease.

Our study shows, childhood diarrhea has declined over the years significantly, yet contributes to a larger share of DALYs associated with the disease. Among all the death cases of Diarrhea, in 2019, the most prevalent disease-causing pathogen is found to be Campylobacter. But Adenovirus is the major contributor to childhood diarrheal deaths. Though the burden of diarrhea is declining over the period, still there is a need to progress the interventions to prevent and control diarrhea rapidly to avoid the huge number of deaths and disabilities experienced in India.

Conclusions

Consumption of safe and clean water, proper sanitation facility in every household, required nutrition intake by mother and child, safe breastfeeding and stool disposal practices and careful case management, rotavirus vaccination are some of the effective interventions to be implemented all over the country. Further, evidence-based policies should be made and implemented to sustain diarrhea prevention programs.

Peer Review reports

The epidemiological transition from communicable diseases to non-communicable diseases has shifted the attention of public health researchers accordingly in recent years. Yet, the morbidity, mortality, and disability associated with communicable diseases, or so-called primitive diseases, are still significant. Among all, Diarrhea is one of the top 10 diseases to contribute to global DALY, even in recent years. It is found to be one of the most common diseases among children under-5 years [ 1 ]. Diarrhea is a disease that has different kinds to it, according to ICD-10, such as infective neonatal diarrhea, unspecified diarrhea, functional diarrhea, non-infective neonatal diarrhea, and irritable bowel syndrome with diarrhea, etc. [ 2 ]. Along with the diseased person, it also affects the well-being of the ICU health workers due to the increasing workload. Heidegger et al. say diarrhea episodes have a huge impact on human-related costs and so on the financial burden in ICU [ 3 ].

In low and middle-income countries, diarrhea possess a great threat to the population and its economy. In these countries, the prevalence of diarrheal disease seems to be rather increasing with time while poverty is a major factor influencing this trend. Ahs et al. argue that current diarrhea-related mortality among children is a result of inequity in resource distribution such as insufficient health care staff, unequal access to healthcare services [ 4 ]. Not having enough knowledge on care-seeking behavior and case management practices lead to poor case management of childhood diarrhea in LMICs, hence need improvement [ 5 ]. Reportedly, harmful practices such as restrictions of fluid or breast milk during diarrhea, administration of modern medicine in the wrong manner in the process of diarrhea management rather have negative health outcomes and possibly create conflicts with WHO treatment regimen [ 6 ]. Adapting healthy practices such as building sanitation infrastructure, consumption of safely managed water, and reducing diarrhea-associated mortality in high-income countries is evident [ 7 ].

Mortality due to diarrheal disease has been declining due to various preventive measures taken at an individual and national level, yet the incidence remains constant. Apart from this, cured individuals also contribute to various other kinds of public health burdens such as impaired cognitive development, reduced immune response, growth faltering, and death, at times [ 8 , 9 ]. Along with LMICs, even HICs have to carry huge public health and economic burden associated with it. One of the most developed countries, the United States of America, lost approximately 6 billion US dollars/ year due to medical expenses and resulting unproductivity [ 10 ].

Even after being one of the leading causes of mortality and morbidity in the world, data associated with diarrheal diseases are limited [ 1 ]. As for the etiological causes, although there are many e.g., viruses, bacteria, parasites, etc., there is no gold standard for it [ 11 ]. Risk factors that can make a population more vulnerable to diarrhea can be environmental or behavioral, yet differ among individuals, populations, countries, and geographies.

This study aims to measure the burden of diarrhea in India in 2019 and analyze the trend of mortality associated with it for the past 30 years. We also intend to find the prevailing etiology and risk factors associated with diarrheal deaths in India in the year 2019. The rest of the paper is divided into four sections. Section 2 discusses methods. Section 3 contains the results. Section 4 critically discusses the results. Finally, section 5 concludes the study.

The study has used the latest round of GBD study 2019, which is a comprehensive database related to communicable diseases, non-communicable diseases, and injuries over the period from 1990 to 2019 across the 204 country samples [ 12 ]. The latest round of GBD survey-2019 provides information about 369 diseases and injuries related incidence, death, and disability adjust life years (DALYs). Additionally, it provides information about 87 risk factors of the cause of disease and etiologies. This data is available across age groups and gender-wise over the period from 1990 to 2019. In this study, we have analyzed the data related to Diarrhea disease – number of deaths, mortality rate, DALYs rate, associated risk factors, etiologies in India. The study has identified 13 etiologies for the cause of diarrhea deaths (see Table  2 ) and 20 risk factors (see Table  3 ) to analyze the burden of disease. The analysis has been done across the period, across age groups, and across gender in India. Additional file  1 : Table A1 shows the indicators and measurement criteria have used in the study.

Burden of diarrhea – number of deaths, mortality, and DALYs

Table  1 presents the number of diarrhea deaths and mortality rate (per 100,000 population) in 2019 in India for each age group and sex. The latest data in 2019 shows, the total number of deaths of all ages is 632,344 in 2019 (95% uncertainty interval; 358,561–1,056,036), and the mortality rate is 45 per 100,000 population (95% uncertainty interval; 25–75). Most deaths occurred in the older age group – 70+ years followed by 50–69 years in 2019. It has estimated that the mortality rate 682 (95% uncertainty interval: 362–1144) for 70+ years and 62 95% (uncertainty interval: 31–118) for 50–69 years in 2019. Similarly, the number of child deaths in the age group - Under 5 is 55,309 in 2019 (95% uncertainty interval: 39882–73,621), and the mortality rate is 47 per 100,000 population (95% uncertainty interval; 34–62).

Table 1 also presents gender-wise differences in diarrhea-related deaths and mortality in India in 2019. It has been shown that the number of deaths of males and females is 32.31 (95% uncertainty interval: 20.01–67.64) and 59.31 (95% uncertainty interval: 24.53–117.11) respectively of all age groups. These mortality differences between males and females are also exhibited in other age categories as well and it is clearly shown that females are more prone to diarrhea-related deaths than males. The differences in mortality are more widened in the age group 70+ years where the female mortality rate is 846.84 (95% uncertainty interval: 327.30–1683.73) and 495.20 (95% uncertainty interval: 295.49–1026.31). Similarly, child mortality is more prone due to the cause of diarrhea, and the gender difference between a male and female child is visible in Table 1 .

Figure  1 shows the time-series trends in Diarrhea mortality rate (per 100,000 population) by age in India from 1990 to 2019. All ages: The mortality rate has been declined from 126 in 1990 to 45 in 2019. Under − 5: The mortality rate has been declined from 309 in 1990 to 47 in 2019. Five to fourteen years: The mortality rate has been declined from 27 in 1990 to 6 in 2019. Fifteen to forty-nine years: The mortality rate has been declined from 27 in 1990 to 6 in 2019. Fifty to sixty-nine years: The mortality rate has been declined from 236 in 1990 to 63 in 2019. 70+ years: The mortality rate has been declined from 2104 in 1990 to 682 in 2019. The overall analysis of Fig.  1 depicts that the deaths of diarrhea have been declined over the period across all age groups in India but still it plays a major communicable disease in India.

figure 1

Diarrhea mortality rate (per 100,000 population) by age, 1990–2019 in India. Note: Point represent mean estimates and error bars represents 95% uncertainty interval of the lower and upper limit

Figure  2 shows the time-series trends in Diarrhea DALYs rate (per 100,000 population) by age in India from 1990 to 2019. All ages: The DALYs rate has been declined from 6544 in 1990 to 1446 in 2019. Under − 5: The DALYs rate has been declined from 27,351 in 1990 to 4283 in 2019. Five to fourteen years: The DALYs rate has been declined from 2474 in 1990 to 705 in 2019. Fifteen to forty-nine years: The DALYs rate has been declined from 1591 in 1990 to 531 in 2019. Fifty to sixty-nine years: The DALYs rate has been declined from 7067 in 1990 to 2017 in 2019. 70+ years: The DALYs rate has been declined from 30,904 in 1990 to 9242 in 2019. The overall analysis of Fig.  2 depicts that the DALYs rate of diarrhea has been declined over the period across all age groups in India but still around 705 persons of all ages are living with disabilities in 2019. Similarly, the under-5 and older age (i.e., 70+ years) are more DALYs rate that is 4283 and 9242 persons in 2019 respectively.

figure 2

Diarrhea DALYs rate (per 100,000 population) by age, 1990–2019 in India. Note: Point represent mean estimates and error bars represents 95% uncertainty interval of the lower and upper limit

Etiologies for the cause of diarrhea disease and deaths

Table 2 represents etiologies for the cause of diarrhea disease and the number of deaths among under-5 and all ages in India, 2019. We have found that there is 13 etiology that causes diarrhea in India. We have found that Adenovirus is the most prominent pathogen for the cause of diarrhea among children, followed by Campylobacter and Cryptosporidium. Our result shows that around 8864 deaths occurred due to Adenovirus whereas around 8435 for Campylobacter and 5074 for Cryptosporidium in 2019. Similarly, the most pertinent pathogen for the cause of diarrhea for all ages is Campylobacter followed by Cryptosporidium and Norovirus. Our results show that around 44,353 deaths occurred due to Campylobacter whereas around 36,007 for Cryptosporidium and 29,924 for Norovirus in 2019.

Risk factors for the cause of diarrhea disease and mortality

Table 3 shows the risk factors for the cause of diarrhea disease and mortality rate (per 100,000) among under-5 and all ages in India, 2019. We have found many environmental and behavioral risk factors that lead to diarrhea. The environmental factors include unsafe water, sanitation, and handwashing; and air pollution (i.e., ambient particulate matter pollution and household air pollution from solid fuels). The behavioral factors include suboptimal breastfeeding; malnutrition; vitamin A deficiency. Our result shows that major risk factors of diarrhea-related child mortality are unsafe water sources followed by child wasting and unsafe sanitation. It is shown that the under-5 diarrhea-specific mortality rate is 43 (95% uncertainty interval: 30–59) due to unsafe water, sanitation, and handwashing factors. Similarly, the mortality rate is 44 (95% uncertainty interval: 32–59) due to child and maternal malnutrition factors. Our result shows that major risk factors of diarrhea-specific mortality of all ages are unsafe water sources. It is shown that the all-ages diarrhea-specific mortality rate is 41 (95% uncertainty interval: 23–69) due to unsafe water, sanitation, and handwashing factors. Overall analysis shows that unsafe water, sanitation, and handwashing practices are the major risk factors for diarrhea-specific mortality in India of all ages as well as under-5 in India. But risk factors such as Suboptimal breastfeeding, Child growth failure, and low birth weight, and Vitamin A deficiency are the pertinent factors for the cause of diarrhea-specific mortality for children (i.e., Under 5) in India.

Changing pattern of diarrhea cases in India

As our study suggests the overall morbidity and mortality associated with diarrheal disease has declined from 1990 till 2019, a similar pattern of diarrhea cases has been observed in India and different parts of the world by several public health researchers so far.

Troeger et al. have studied diarrhea burden in different regions of the world and found that although the disease burden associated with diarrhea has been declining over the years, it still is one of the biggest threats among children under 5 years and the elderly population specifically i.e., more than 70 years old [ 13 ]. In 2015, although children under 5 years had the highest number of deaths due to diarrhea among all age groups in Eastern Mediterranean Region, 17 out of 22 countries showed higher mortality among the elderly (70+) population than any other age group [ 14 ]. Similarly, this study also depicts the highest mortality among the elderly population, making them more vulnerable.

As the result of our study shows, childhood diarrhea has declined over the years significantly, yet contributes to a larger share of DALYs associated with the disease. In India, as most of the low-and middle- income countries, diarrheal proportional mortality has always been high among children even after a steady decline in childhood diarrhea deaths [ 15 ]. Being the 2nd largest cause of the under-5 mortality rate of Ethiopia, in 2013 since 1990, it shows diarrhea not only causes disability and discomfort in the younger population but also leads to deaths for a very long period [ 16 ].

Prevailing pathogens and risk factors of diarrhea

Among all the death cases of Diarrhea, in 2019, the most prevalent disease-causing pathogen is found to be Campylobacter. But, Adenovirus is the major contributor to childhood diarrheal deaths. While most of the existing literature from all over the world suggests Rotavirus being the major cause of childhood diarrhea, the number of deaths associated with it among the children under 5 years in our study is relatively much lesser i.e., 2059.74 per 100,000 population, compared to Adenovirus i.e., 8864.36 per 100,000 populations. Even though Rotavirus does not cause the greatest number of deaths, it still is one of the major fatal pathogens. Reportedly, these deaths can be reduced by promoting and implementing the rotavirus vaccine in the country. By averting more than 28,000 deaths of young children around the globe, in 2016, the rotavirus vaccine has proved its efficiency [ 17 ].

As our study indicates that unsafe water, sanitation, and handwashing practices with child growth failure, LBW has a major role in increased morbidity and mortality associated with childhood diarrhea (or diarrhea in general), similarly, Lakshminarayanan and Jayalakshmy have also found a significant association of such risk factors with childhood diarrhea along with other types of risk factors. These include – age, socio-economic status, unhealthy breastfeeding practices, low birth weight, having younger siblings, etc. [ 15 ]. This finding is also parallel with many other existing public health literature by various researchers. In rural Mozambique, washing hands facilities with child stool disposal system has a noticeable impact on reduced risk of middle to severe diarrhea among children, and not providing fresh drinking water has contributed to a higher risk of childhood diarrhea [ 18 ]. In a study regarding diarrhea in urban slums of India, it was also seen that the incidence of diarrhea is relatively higher among children of poor (lower SES) strata [ 19 ]. While most of the discussion about the risk factor of diarrhea is concentrated around the consumption of unsafe water and poor sanitation, predisposing factors such as unsafe medium of drinking water conveyance, poor condition of water tanks at houses, water handling practices at households, improper disposal of wastewater and fecal matter, etc. are essential to look for to prevent diarrhea [ 20 , 21 ]. Surprisingly, although not in our study, many studies have shown that the attack rate of diarrhea is higher among families with more than one child under 5 years of age than families with a single child [ 22 ].

Apart from these aforementioned factors, the knowledge, attitude, and behavior of mothers have also a significant impact on diarrhea among the younger population. Singh et al. have found a positive correlation between the educational status of a mother with the incidence of diarrheal disease [ 23 ]. Further, the literacy status of the mother can also be associated with the risk behaviors they practice at their households such as not washing hands before feeding the child, washing hands without soap, improper disposal of stools, etc. [ 24 ]. In our study, as well, the mortality rate associated with diarrhea among the under-5 cohort differs due to different types of breastfeeding behavior shown by mothers. As the children are not capable of taking the decision, hence, parents are needed to make healthy decisions for their children and the family, as a whole.

Child and maternal malnutrition are a well-acknowledged risk factor of diarrhea for ages and a similar result is also observed in our study. But in some studies, the frequency of diarrhea was found to be not significantly related to the nutritional status of the children [ 25 ]. Similarly, Ganguly et al. found that although malnutrition is significantly associated with diarrhea, there is no significant association with lack of breastfeeding, low literacy status of the mother, and consumption of untreated drinking water [ 26 ]. These findings suggest that although there are tons of literature in place, still there is a need for more research regarding risk factors of diarrhea as it may differ between countries, regions, populations, or age groups.

Using global burden of disease data, this study was examined the burden of diarrhea, etiologies, and risk factors in India over the last 30 years from 1990 to 2019. We have found that most deaths occurred in the older age group – 70+ years followed by 50–69 years in 2019. Study results also show that childhood diarrhea has declined over the years significantly. Among all the death cases of Diarrhea, in 2019, the most prevalent disease-causing pathogen is found to be Campylobacter. But Adenovirus is the major contributor to childhood diarrheal deaths. Though the burden of diarrhea is declining over the period, still there is a need to progress the interventions to prevent and control diarrhea rapidly to avoid the huge number of deaths and disabilities experienced in India. Consumption of safe and clean water, proper sanitation facility in every household, required nutrition intake by mother and child, safe breastfeeding and stool disposal practices and careful case management, rotavirus vaccination are some of the effective interventions to be implemented all over the country. Along with these, more public health research regarding prevalence, etiology, and risk factors should be carried out in the future. Further, evidence-based policies should be made and implemented to sustain diarrhea prevention programs.

Availability of data and materials

Data is available in the public domain for research purposes and not for commercial use. Data can be obtained from the open access repository of the Institute of Health Metrics Evaluation (IHME).

Abbreviations

Disability Adjust Life Years

Global Burden of Disease

Hospital Incident Command System

Institute for Health Metrics and Evaluation

International Classification of Diseases

Intensive Care Unit

Low-and Middle Income Countries

World Health Organization

Fischer Walker CL, Perin J, Aryee MJ, Boschi-Pinto C, Black RE. Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review. BMC Public Health. 2012;12(1):220 https://doi.org/10.1186/1471-2458-12-220 .

Article   Google Scholar  

Ma C, Wu S, Yang P, Li H, Tang S, Wang Q. Behavioural factors associated with diarrhea among adults over 18 years of age in Beijing, China. BMC Public Health. 2014;14(1):451 https://doi.org/10.1186/1471-2458-14-451 .

Heidegger C-P, Graf S, Perneger T, Genton L, Oshima T, Pichard C. The burden of diarrhea in the intensive care unit (ICU-BD). A survey and observational study of the caregivers’ opinions and workload. Int J Nurs Stud. 2016;59:163–8 https://doi.org/10.1016/j.ijnurstu.2016.04.005 .

Ahs JW, Tao W, Löfgren J, Forsberg BC. Diarrheal diseases in Low- and middle-income countries: incidence, prevention and management. Open Infect Dis J. 2010;4(1) https://doi.org/10.2174/1874279301004010113 .

Sreeramareddy CT, Low Y-P, Forsberg BC. Slow progress in diarrhea case management in low and middle income countries: evidence from cross-sectional national surveys, 1985–2012. BMC Pediatr. 2017;17(1):83 https://doi.org/10.1186/s12887-017-0836-6 .

Carter E, Bryce J, Perin J, Newby H. Harmful practices in the management of childhood diarrhea in low- and middle-income countries: a systematic review. BMC Public Health. 2015;15(1):788 https://doi.org/10.1186/s12889-015-2127-1 .

Prüss-Ustün A, Wolf J, Bartram J, Clasen T, Cumming O, Freeman MC, et al. Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: an updated analysis with a focus on low- and middle-income countries. Int J Hyg Environ Health. 2019;222(5):765–77 https://doi.org/10.1016/j.ijheh.2019.05.004 .

Khalil I, Colombara DV, Forouzanfar MH, Troeger C, Daoud F, Moradi-Lakeh M, et al. Burden of diarrhea in the eastern Mediterranean region, 1990–2013: findings from the global burden of disease study 2013. Am J Trop Med Hyg. 2016;95(6):1319–29 https://doi.org/10.4269/ajtmh.16-0339 .

Ricci KA, Girosi F, Tarr PI, Lim Y-W, Mason C, Miller M, et al. Reducing stunting among children: the potential contribution of diagnostics. Nature. 2006;444(1):29–38 https://doi.org/10.1038/nature05444 .

Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, et al. Practice guidelines for the Management of Infectious Diarrhea. Clin Infect Dis. 2001;32(3):331–51 https://doi.org/10.1086/318514 .

Article   CAS   Google Scholar  

Operario DJ, Houpt E. Defining the etiology of diarrhea: novel approaches. Curr Opin Infect Dis. 2011;24(5):464–71 https://doi.org/10.1097/QCO.0b013e32834aa13a .

IHME. Global Burden of Disease Study 2019 (GBD 2019) Results. Global Burden of Disease Collaborative Network, vol. 2020. United States: Institute for Health Metrics and Evaluation (IHME); 2020.

Google Scholar  

Troeger C, Blacker BF, Khalil IA, Rao PC, Cao S, Zimsen SR, 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(11):1211–28 https://doi.org/10.1016/S1473-3099(18)30362-1 .

GBD 2015 Eastern Mediterranean Region Diarrhea Collaborators. Burden of diarrhea in the eastern Mediterranean region, 1990–2015: findings from the global burden of disease 2015 study. Int J Public Health. 2018;63:109–21 https://doi.org/10.1007/s00038-017-1008-z .

Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: current scenario and future perspectives. J Nat Sci Biol Med. 2015;6(1):24–8 https://doi.org/10.4103/0976-9668.149073 .

Deribew A, Tessema GA, Deribe K, Melaku YA, Lakew Y, Amare AT, et al. Trends, causes, and risk factors of mortality among children under 5 in Ethiopia, 1990–2013: findings from the global burden of disease study 2013. Popul Health Metrics. 2016;14(1):42 https://doi.org/10.1186/s12963-016-0112-2 .

Troeger C, Khalil IA, Rao PC, Cao S, Blacker BF, Ahmed T, et al. Rotavirus vaccination and the global burden of rotavirus diarrhea among children younger than 5 years. JAMA Pediatr. 2018;172(10):958–65 https://doi.org/10.1001/jamapediatrics.2018.1960 .

Nhampossa T, Mandomando I, Acacio S, Quintó L, Vubil D, Ruiz J, et al. Diarrheal disease in rural Mozambique: burden, risk factors and etiology of diarrheal disease among children aged 0–59 months seeking Care at Health Facilities. PLoS One. 2015;10(5):e0119824 https://doi.org/10.1371/journal.pone.0119824 .

Gupta P, Murali MV, Seth A. Epidemiology of diarrhea in urban slums. Indian Pediatr. 1998;35:5.

Simiyu S. Water risk factors pre-disposing the under five children to diarrhoeal morbidity in Mandera District, Kenya. East Afr J Public Health. 2010;7(4):Article 4 https://doi.org/10.4314/eajph.v7i4.64761 .

Kumar SG, Subita L. Diarrhoeal diseases in developing countries: a situational analysis. Kathmandu Univ Med J. 2012;10(2):83–8 https://doi.org/10.3126/kumj.v10i2.7351 .

Reddaiah VP, Kapoor SK. Epidemiology of diarrhea and its implications for providing services. Indian J Pediatr. 1991;58(2):205–8 https://doi.org/10.1007/BF02751121 .

Singh J, Gowriswari D, Chavan BR, Patiat RA, Debnath AC, Jain DC, et al. Diarrhoeal diseases amongst children under five. A study in rural Alwar. J Commun Dis. 1992;24(3):150–5.

CAS   PubMed   Google Scholar  

Ghosh S, Sengupta PG, Mondal SK, Banu MK, Gupta DN, Sircar BK. Risk behavioural practices of rural mothers as determinants of childhood diarrhoea. J Commun Dis. 1997;29(1):7–14.

Anand K, Sundaram KR, Lobo J, Kapoor SK. Are diarrheal incidence and malnutrition related in under five children? A longitudinal study in an area of poor sanitary conditions. Indian Pediatr. 1994;31(8):943–8.

Ganguly E, Sharma PK, Bunker CH. Prevalence and risk factors of diarrhea morbidity among under-five children in India: a systematic review and meta-analysis. Indian J Child Health. 2015;2(4):152.

Download references

Acknowledgments

We thank anonymous referees, the editor-in-chief, and manageing editor of the journal for their suggestions and comments to improve the paper. We would also like to thank IHME for the permission to download the data from their repository. However, the usual disclaimer applies.

Statement of human and animal rights

Not Applicable.

The GBD study is funded by the Bill and Melinda Gates Foundation.

Author information

Authors and affiliations.

Faculty of Health Economics, Department of Commerce, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576 104, India

Deepak Kumar Behera

The Medics, Angul, Odisha, 759122, India

Sanghamitra Mishra

You can also search for this author in PubMed   Google Scholar

Contributions

DKB contributed to study design. DKB analyzed the data and SM verified the results. DKB drafted the first version of the manuscript and SM edited the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Deepak Kumar Behera .

Ethics declarations

Ethics approval and consent to participate.

The protocol for Global Budern of Disease study follow Institute of Health Metrics Evaluation (IHME) criteria and outlined in the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: table a1..

Definition of Variables and measurement.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Behera, D.K., Mishra, S. The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: evidence from the global burden of disease study. BMC Public Health 22 , 92 (2022). https://doi.org/10.1186/s12889-022-12515-3

Download citation

Received : 08 August 2021

Accepted : 05 January 2022

Published : 13 January 2022

DOI : https://doi.org/10.1186/s12889-022-12515-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Burden of diarrhea
  • Etiology of diarrhea
  • Risk factor for diarrhea
  • Burden of disease, India

BMC Public Health

ISSN: 1471-2458

literature review of diarrhea

U.S. flag

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006.

Cover of Disease and Mortality in Sub-Saharan Africa

Disease and Mortality in Sub-Saharan Africa. 2nd edition.

Chapter 9 diarrheal diseases.

Cynthia Boschi-Pinto , Claudio F. Lanata , Walter Mendoza , and Demissie Habte .

Of the estimated total 10.6 million deaths among children younger than five years of age worldwide, 42 percent occur in the World Health Organization (WHO) African region ( Bryce et al. 2005 ). Although mortality rates among these children have declined globally from 146 per 1,000 in 1970 to 79 per 1,000 in 2003 ( WHO 2005 ), the situation in Africa is strikingly different. As compared with other regions of the world, the African region shows the smallest reductions in mortality rates and the most marked slowing down trend ( figure 9.1 ). The under-five mortality rate in the African region is seven times higher than that in the European region. In 1980 this difference was equal to 4.3 times ( WHO 2005 ).

Slowing Progress in Child Mortality (per 1,000 births) Source: Adapted from WHO 2005.

During the 1990s, the decline of under-five mortality rates in 29 countries of the world stagnated, and in 14 countries rates went down but then increased again. Most of these countries are from the African region ( WHO 2005 ). A factor that may contribute to this situation is the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic in the region, but an underlying weakness of the implementation capacity of the health system is also likely to blame ( Walker, Schwartländer, and Bryce 2002 ).

Similarly to all-cause mortality, global estimates of the number of deaths due to diarrhea have shown a steady decline, from 4.6 million in the 1980s ( Snyder and Merson 1982 ) to 3.3 million in the 1990s ( Bern et al. 1992 ) to 2.5 million in the year 2000 ( Kosek, Bern, and Guerrant 2003 ). However, diarrheal diseases continue to be an important cause of morbidity and mortality worldwide, and despite all advances in health technology, improved management, and increased use of oral rehydration therapy (ORT) in the past decades, they remain among the five major killers of children under five years of age.

In contrast to mortality trends, morbidity due to diarrhea has not shown a parallel decline, and global estimates remain between two and three episodes of diarrhea per child under five per year. Kosek, Bern, and Guerrant (2003) estimated a global median incidence of diarrhea to be 3.2 episodes per child-year in the year 2000, similar to those found in previous reviews by Snyder and Merson (1982) and by Bern and colleagues (1992) as well as to those reported in the first edition of Disease Control Priorities in Developing Countries ( Jamison et al. 1993 ).

This chapter reviews available information published since the 1980s on the morbidity and mortality burden of diarrheal diseases in children under five years of age in the WHO African region.

Reliable and comparable estimates of morbidity and mortality are difficult to obtain because of variations in methodology, failure to standardize case definitions of diarrhea, and seasonal nature of the disease, among other factors. Nevertheless, such estimates, mainly based on the available studies in the literature, are provided here.

HIV infection has added considerably to the burden of diarrheal diseases among adults and children. This is of particular importance in African countries that show high HIV prevalence. However, the scarcity of data makes it difficult to quantify comorbidity and its contribution to the mortality burden. Because of the probable influence of HIV/AIDS, especially in the mortality due to diarrheal disease, we have followed the WHO's division of the African region into two subregions, which takes into account mortality levels: the AFR D subregion (high child and high adult mortality) and the AFR E subregion (high child and very high adult mortality). Stratum E includes the countries in Sub-Saharan Africa where HIV/AIDS has had a substantial impact ( Mathers et al. 2002 ). Specific estimates have been provided for each subregion whenever available data permitted. Countries included in each subregion are listed in appendix table 9A.1 .

Table 9A.1. Regional Reporting Categories for Global Burden of Disease 2000: WHO African Subregions.

Regional Reporting Categories for Global Burden of Disease 2000: WHO African Subregions.

  • Data Sources and Literature Review: Morbidity

The usual sources of diarrhea morbidity data are either national surveys, such as Demographic and Health Surveys (DHSs) and the United Nations Children's Fund (UNICEF) Multiple Indicator Cluster Surveys ( MICS, conducted from 1996 to 2000; http://www.childinfo.org/MICS2/Gj99306k.htm , accessed April 12, 2003), or the published literature.

The main limitation of using currently available national survey data to estimate diarrhea morbidity is the cross-sectional nature of data collection. The information obtained from these surveys is of diarrhea prevalence in the two weeks previous to the survey, which does not account for seasonality. Therefore, data are not comparable either across sites or over time. Moreover, there is a potential for important recall bias in such morbidity surveys ( Boerma et al. 1991 ; Snow et al. 1993 ). Some of the major limitations of longitudinal studies are lack of representativeness, possible site bias, low frequency of surveillance visits, and recall bias.

Most reviews carried out so far ( Bern et al. 1992 ; Kosek, Bern, and Guerrant 2003 ; Snyder and Merson 1982 ) have relied on published studies to estimate the incidence or prevalence of diarrheal disease. Some of the limitations of this type of study are the small number of data points and the lack of representativeness, given the specific sites where most studies are carried out.

The most recent morbidity review ( Kosek, Bern, and Guerrant 2003 ) included five prospective studies from African countries, carried out between 1987 and 1990: two studies were from the AFR D subregion (Guinea-Bissau and Nigeria) and three from the AFR E subregion (Democratic Republic of Congo, Kenya, and Zimbabwe). These studies are listed in appendix table 9A.2 .

Table 9A.2. Main Characteristics of the Studies Included in the Morbidity Review.

Main Characteristics of the Studies Included in the Morbidity Review.

  • Data Sources and Literature Review: Mortality

Nationally representative surveys such as the DHS do not usually report causes of death, but the number of diarrhea-associated deaths can be obtained from either vital statistics registration systems or from special study populations. From each of these sources, the proportion of deaths attributed to diarrhea can be estimated as well as diarrhea mortality rates. However, the representativeness and accuracy of the data vary according to the type of source and various study design features.

The main limitations of vital registration systems are underreporting of the number of deaths and miscoding of the causes of death. Most of the limitations described for the use of longitudinal studies for estimating morbidity also apply to mortality estimation, such as lack of representativeness, possible site bias, and misclassification of the causes of death.

The only countries in the African region for which there is some reported vital registration (VR) coverage are Mauritius, South Africa, and Zimbabwe. The coverage for Mauritius was reported to be 100 percent in the year 2000. Only 1.4 percent of all deaths among children under five were due to diarrhea in this country. The latest information available for South Africa and Zimbabwe (1996 and 1990, respectively) reported estimated coverage rates of less than 50 percent ( http://www.who.int/whosis/mort/table4 ). Therefore, in the African region, most information on cause-specific mortality relies on special studies available in the literature.

The studies included in our review were identified by a systematic search of the scientific literature published since 1980, performed through the WHO's library on Medline/Pubmed using the following terms: Africa, mortality, different spellings of "diarrhea," and all terms combined. No restriction was placed on publication language. The reference sections of these studies were then reviewed to identify additional studies.

The review performed by Kirkwood (1991) for the previous edition of Disease and Mortality in Sub-Saharan Africa included data from cross-sectional studies and from national diarrhea programs. In the current review we have considered only longitudinal studies. Inclusion criteria were the following: studies carried out in countries from Sub-Saharan Africa, studies published from 1980 on, studies containing diarrhea-specific mortality data, studies containing a minimum of 25 total deaths, community-based studies with at least one year of follow-up, and a follow-up time multiple of 12 months to minimize seasonal effects.

Twenty-four studies were identified that met the above criteria and were therefore included in this review ( appendix table 9A.3 ). They were carried out in 15 (33 percent) of the 46 countries of the African region: seven were carried out in countries from AFR D, and eight from AFR E. Figure 9.2 illustrates the countries and the sites in each country for which studies were available.

Table 9A.3. Main Characteristics of the Studies Included in the Mortality Review.

Main Characteristics of the Studies Included in the Mortality Review.

Sites with Available Under-Five Diarrhea Mortality Data Source: Authors.

The 24 longitudinal studies identified in the current literature represent an important increase in information when compared with the 7 available studies included in the previous review ( Kirkwood 1991 ). There has been more than a threefold increase in the available literature of longitudinal studies reporting diarrhea mortality in Sub-Saharan Africa. This increase in the number of publications from Sub-Saharan Africa resulted in a doubled number of African countries for which diarrhea mortality data were available, thus adding to the precision of the current estimates.

  • Data Source and Literature Review: Etiology

Similarly to what was described for morbidity and mortality estimates, the main data source to estimate diarrheal etiology is the published literature. We conducted a search of papers published since 1990, using Medline/Pubmed; the terms used were as follows: Africa, Sub-Saharan Africa, diarrhea, etiology, epidemiology, and children. Different spellings as well as combinations of terms were also considered. In addition, we considered keywords for specific etiologies known to cause diarrhea in children. Articles published in languages other than English, Spanish, Portuguese, Italian, and French that did not have an English abstract were not included. Further sources were identified from cross-references, consultation with experts in the field, and use of the "related articles" link in PubMed.

We used the following inclusion criteria: studies carried out at community level, among outpatient and inpatient health services; studies that covered at least 12 months of surveillance; and studies in which one or more causes of diarrhea were identified through the use of standard laboratory procedures. Exclusion criteria were studies reporting diarrhea outbreaks, studies carried out among children with HIV/AIDS, studies reporting nosocomial infections, and studies carried out in day-care centers.

Thirty-four studies were identified that met the above criteria, covering 12 African countries, 6 from each of the two African subregions. These are listed in appendix table 9A.4 .

Table 9A.4. Main Characteristics of the Studies Included in the Etiology Review.

Main Characteristics of the Studies Included in the Etiology Review.

  • Reviews and Estimations

In the 1980s Snyder and Merson (1982) reviewed 24 published studies in order to estimate morbidity and mortality from diarrheal disease. Three of these studies, carried out in the African region (Ethiopia, Kenya, and Nigeria), reported the annual number of episodes of diarrhea per child by age group.

In an attempt to update these estimates, Bern and colleagues (1992) reviewed articles published between 1980 and 1990. There were seven studies available for the African regions, covering three countries: The Gambia, Ghana, and Nigeria.

Kosek, Bern, and Guerrant (2003) included four studies from the African region in their review, which had been carried out in the Democratic Republic of Congo, Guinea-Bissau, Kenya, Nigeria, and Zimbabwe ( appendix table 9A.2 ). Table 9.1 summarizes the results from these studies. Unlike mortality, estimates of morbidity due to diarrhea do not show a decline over time, according to the reviews carried out. Estimates remain consistent for all age groups for which data are available. However, the number of observations, varying from three to five, is low for all three studies, and the uncertainty that prevails because of this low number and the different sites where the studies were carried out should be taken into account when interpreting these data.

Table 9.1. Median Estimates of Episodes of Diarrhea per Child per Year in the African Region, by Age Group.

Median Estimates of Episodes of Diarrhea per Child per Year in the African Region, by Age Group.

Because some of the mortality studies were carried out in more than one country or more than one point in time, they provided a total of 27 data points to be included in the analysis. More than 50 percent of these 27 data points showed proportions of diarrhea mortality between 12 percent and 17 percent; 19 out of the 27 data points (70 percent) had proportions between 12 percent and 19 percent; and only 8 data points provided proportions greater than 20 percent. Because of the skewness of the frequency distributions, we chose to use medians rather than means to calculate diarrhea proportional mortality for each African subregion.

We have used two different approaches to estimate the numbers and proportions of diarrhea deaths for Sub-Saharan Africa in the year 2000: calculation of simple medians for each African subregion and extrapolation from the regression of medians of diarrhea proportional mortality against time.

Simple Medians of Diarrhea Proportional Mortality

As a first approach to estimating the number of deaths due to diarrhea among children younger than five years of age in the African region for the year 2000, we applied the median of the proportions of diarrhea deaths to the total number of deaths among children under five in each of the two African subregions. These medians were similar for the two subregions: 17.7 percent (interquartile intervals [IQI] 12.7–24.5 percent) in AFR D and 17.6 percent (IQI 12.9–19.3 percent) in AFR E. The WHO estimates that approximately 4.3 million children under five died in Africa in the year 2000: 2.0 million in AFR D and 2.3 million in AFR E (WHO, unpublished data). Applying the proportion of diarrhea deaths estimated to have occurred among children under five in Sub-Saharan Africa in the year 2000 to the total number of deaths in these children in that same year yields an approximate total of 760,000 diarrheal deaths.

Proportions over Time

It has been suggested that at least for some countries diarrhea mortality has been declining over the past years, mostly due to the spread of ORT use ( Baltazar, Nadera, and Victora 2002 ; Miller and Hirschhorn 1995 ; Victora et al. 1996 ; Victora et al. 2000 ). We thus examined the medians of the proportions for studies carried out in Sub-Saharan Africa in different time periods.

Because there were only two observations in the late 1970s, we disregarded data from this time period and examined the following time periods: 1980–84, 1985–89, and 1990–94. Figure 9.3 shows that there were virtually no changes in diarrhea proportional mortality (β = −0.055) in the African region over the years 1980–95. Indeed, the medians of the proportion of diarrhea deaths were equal to 16.6 percent in the early 1980s, 17.7 percent in the late 1980s, and 16.1 percent in the early 1990s. If the situation remains the same and no major changes have occurred during more recent years, for which no data were available, the proportion of diarrhea deaths in the year 2000 could be estimated to be equal to 16.2 percent. This corresponds to an estimated total of 700,000 deaths, similar to the estimate obtained with the simple median calculation.

Medians of Diarrheal Proportional Mortality among Children under Five in the African Region, 1980–95 Source: Authors, from studies listed in appendix table 9A.3.

When comparing the median data points observed in the African region with those from other developing regions of the world ( figure 9.4 ), we note that although there was a steep decline in the proportions of diarrhea mortality in the other regions (β = −0.78), virtually no decline was observed in Sub-Saharan Africa. These observations correspond to an approximately 33 percent decline in the proportion of diarrheal deaths between 1980 and 1995 in the other developing regions of the world and basically no changes in the African region.

Medians of Diarrheal Proportional Mortality among Children under Five in the African Region and Other Developing Regions, 1980–95 Source: Authors, from studies listed in appendix table 9A.3.

Comparison of Estimates from Recent Reviews of the Burden of Diarrhea Mortality

Kosek, Bern, and Guerrant (2003) recently reviewed 30 studies from all developing regions of the world that had available data on diarrhea proportional mortality for children under five years of age and that were published in the 1990s. Ten of these studies were from the African region and covered seven different countries (five from AFR D and two from AFR E). The medians of the diarrhea proportional mortality were 23.2 percent in AFR D and 14.2 percent in AFR E. By applying these medians to the total number of deaths among children under five estimated by the WHO in each of the two subregions in the year 2000, estimates of 454,000 deaths for AFR D and 329,000 deaths for AFR E were obtained. These correspond to a total 783,000 deaths for the whole region.

Morris, Black, and Tomaskovic (2003) have also recently reviewed the literature on causes of death among children under five and used a metaregression model with some selected covariates to estimate the proportional distribution of under-five deaths by cause in Sub-Saharan Africa and South Asia. The authors predicted that 21.9 percent (95 percent CI, 15.5–28.2 percent) of all deaths of children up to four years of age in Sub-Saharan Africa in the year 2000 were due to diarrhea, corresponding to a total of 935,000 deaths attributable to diarrhea.

Table 9.2 summarizes the estimates obtained from the main approaches used in this review and from the recent work performed by Kosek, Bern, and Guerrant (2003) and Morris, Black, and Tomaskovic (2003) as well as from the WHO's most recent mean estimates for the period 2000–03 ( WHO 2005 ). Given the uncertainty of the estimates due to the scarcity and limited representativeness of data, a reasonable and plausible range for the numbers and proportions of deaths due to diarrhea among children under five in Africa can be provided by summarizing different approaches from various methodologies and their respective results. The two estimates provided for AFR D were 354,000 (18 percent) and 454,000 deaths (23 percent) and those provided for AFR E were 329,000 (14 percent) and 405,000 deaths (18 percent). By reviewing the five available estimates for the total African region, we might conclude that approximately 750,000 deaths that occurred among children under five in the year 2000 were due to diarrhea, with a range of estimates that varied between 700,000 ( WHO 2005 ) and 935,000 deaths ( Morris, Black, and Tomaskovic 2003 ). Our estimates are similar to the 741,000 deaths estimated by WHO for the African region, and recently published in TheWorld Health Report ( WHO 2005 ).

Table 9.2. Estimated Number and Proportion of Deaths Due to Diarrhea among Children under Five (thousands).

Estimated Number and Proportion of Deaths Due to Diarrhea among Children under Five (thousands).

Our estimates of deaths from diarrhea among children in Sub-Saharan Africa relied on published epidemiological studies using mostly verbal autopsy methods and thus have limitations inherent in the type of data used, such as lack of representativeness and site bias, observations over time, misclassification of the causes of death, and comparability of data from different studies.

The locations of these studies were rarely representative of the entire country population, as they were usually conducted in populations that are either easy to access or have atypical mortality rates. Furthermore, using studies from a few countries to predict distributions for many countries or a region would require empirical external validation, which we were not able to perform because of the unavailability of other sources of data, such as vital registration data for Sub-Saharan Africa or nationally representative surveys that included causes of death. However, we have tried to stratify countries according to their mortality patterns, especially in what concerns mortality due to HIV/AIDS, to minimize discrepancies between them. Although the observations over time should be interpreted with caution because of the different sites where the studies were conducted, this problem was minimized by including a reasonable number of studies from different sites for each of the three time periods under observation, which should provide an average of the distribution of mortality in these sites. Also, it should be kept in mind that these estimates were summarized as one single observation over time for all of Sub-Saharan Africa, based on a few sites from some countries ( figure 9.2 ). As countries often vary widely in many important socioeconomic and health aspects, summarizing data across countries of a region may obscure important differences.

Some studies of childhood deaths in developing countries have shown that causes of death established using verbal autopsy methods are not always consistent with diagnoses based on more complete clinical data ( Kalter, Gray, and Black 1990 ; Mobley et al. 1996 ; Snow et al. 1992 ). However, the estimates of the cause-specific mortality fraction (proportions of deaths attributable to one cause) resulting from verbal autopsy studies may not necessarily be inaccurate, if misclassification is random.

Finally, the studies reviewed used different case definitions of diarrhea as a cause of death and different methods for assigning them, both of which limit their comparability. Any review that attempts to compile and summarize data from the published literature, especially those data that use both standard and nonstandard verbal autopsy as the means of ascertaining cause of death, faces these limitations. However, the thorough literature search and the restrictive inclusion criteria used in this review, such as population-based studies with follow-up time a multiple of 12 months and studies with at least 25 total deaths, ensured that the studies used for the current estimates consisted of the most valid information available.

Enteropathogens, such as rotavirus, entero-adherent pathogenic Escherichia coli (EAEC), and enterotoxigenic Escherichia coli (ETEC), have been identified as important pathogens in diarrheal diseases, and rotavirus, which causes severe complications of diarrhea, has been found to be the most prominent cause of death in the world ( Bern and Glass 1994 ; Bishop 1994 ; Haffejee 1995 ).

The severity of the etiological agent can be assessed by the setting in which it was most frequently isolated (community, inpatients, or outpatients). Less severe agents would be more frequently found in community settings, whereas more severe ones should be more common in either outpatients or (mainly) inpatients. Median proportions of diarrheal episodes attributable to each major cause of diarrhea from community studies could therefore be applied to estimates of diarrhea morbidity to obtain episodes of diarrheal diseases by cause, and median proportions from inpatient studies could be applied to estimates of diarrhea mortality to calculate the number of diarrheal deaths by etiology. However, because of the scarcity of data available for the African region we did not pursue these calculations.

The studies included in the estimates of etiology by setting are listed in more detail in appendix table 9A.4 . Table 9.3 shows the countries for which data on etiology were available by setting (community, inpatients, or outpatients).

Table 9.3. Available Etiology Data, by Country and Study Setting.

Available Etiology Data, by Country and Study Setting.

Tables 9.4 and 9.5 present the estimated median of the proportions of etiological agents identified and corresponding IQI by study site for subregions AFR D and AFR E, respectively. In our review, Giardia lamblia was more frequently isolated among children with diarrhea in the community studies, whereas EAEC was mainly seen among outpatients. Rotavirus was the etiological agent most frequently isolated in both inpatient and outpatient health services. Therefore, it is likely that rotavirus is the leading cause of mortality due to diarrhea in Africa, as has been observed in other parts of the world. Coinfection of various agents was reported in 16 percent and 7 percent of community-level studies in AFR D and AFR E, respectively. Because our review did not include publications of diarrhea outbreaks, the magnitude of Vibrio cholerae , and Shigella dysenteriae type 1 is underrepresented in this review.

Table 9.4. Median of the Proportions of Etiological Agents among Children under Five in the AFR D Subregion, by Study Site.

Median of the Proportions of Etiological Agents among Children under Five in the AFR D Subregion, by Study Site.

Table 9.5. Median of the Proportions of Etiological Agents among Children under Five in the AFR E Subregion, by Study Site.

Median of the Proportions of Etiological Agents among Children under Five in the AFR E Subregion, by Study Site.

Our estimates of the distribution of diarrhea etiology among children in Sub-Saharan Africa relied on published epidemiological studies. The same limitations reported for the morbidity and mortality estimates therefore apply to these etiological estimates. Moreover, very few studies were identified through the literature search for the African region, and of those, not all have attempted to identify the whole set of etiological agents.

  • The Role of Risk Factors for Diarrheal Disease in the African Region

Broadly recognized risk factors for diarrheal diseases include little or no access to safe water and sanitation, as well as poor hygiene and feces disposal practices at home ( Daniels et al. 1990 ; Haggerty et al. 1994 ; LaFond 1995 ; MacDougall and McGahey 2003 ). These and many other factors, such as poor housing and crowding, are intrinsically associated with poverty. Furthermore, poverty usually limits access to health care and restricts appropriate and balanced diets. Inequities in exposure and resistance add up to inequities in coverage of available preventive interventions, access to an appropriate health provider, and care, making poor children more likely to become sick than the better-off children ( Victora et al. 2003 ).

Some studies have identified a few family characteristics as protective factors. These are monogamy of the father, defined residential area ( Vaahtera et al. 2000 ), having a private kitchen, and being cared for by the mother ( Oni, Schumann, and Oke 1991 ). These factors are of special importance in Sub-Saharan Africa, where the AIDS epidemic has led to an unprecedented number of orphans (about 12 million by the end of 2001) that is likely to more than double during this decade ( Dabis and Ekpini 2002 ).

A WHO report on global water supply provides worrisome figures of current and future scenarios for Africa ( WHO 2000 ). Of all the regions in the world, the African region was the only one showing a decline in the proportion of the population that had access to sanitation between 1990 and the year 2000 ( figure 9.5 ).

Change in Sanitation Coverage by Region, 1990–2000 Source: WHO 2000.

Approximately 50 percent (300 million individuals) of the African population have no access to safe water, and 66 percent (400 million individuals) lack access to hygienic sanitation. It is expected that by the year 2020 these figures will rise to 400 million and 500 million, respectively.

Table 9.6 gives data on feces disposal practices at home in urban and rural regions of four African countries. Such practices have provided the rationale for more preventive interventions and are likely to explain the higher prevalence of diarrheal disease in rural areas. As in most developing regions of the world, African countries' poorest populations live in rural areas. Table 9.7 presents the medians of the prevalence of diarrheal disease according to urban and rural areas.

Table 9.6. Feces Disposal Practices at Home, by Urban and Rural Residences in Four African Countries (percent).

Feces Disposal Practices at Home, by Urban and Rural Residences in Four African Countries (percent).

Table 9.7. Prevalence (Median) of Diarrheal Disease, the Two Weeks before Survey, by Urban and Rural Site of Residence in AFR D and AFR E (percent).

Prevalence (Median) of Diarrheal Disease, the Two Weeks before Survey, by Urban and Rural Site of Residence in AFR D and AFR E (percent).

  • Some Additional Comments

There is an increasing concern that gender disparities might influence the distribution of ill-health and treatment, particularly in under-five girls. Some evidence suggests that girls in developing countries are prone to higher mortality and poorer nutritional status than boys ( Helen Keller International 1994 ; Sundary 1986 ). In Sub-Saharan Africa, few prospective studies lasting at least one year report sex differences at the community level ( Perch et al. 2001 ). Some prospective studies conducted in health facilities on outpatients ( Gomwalk et al. 1993 ; Gomwalk, Gosham, and Umoh 1990 ) and inpatients ( Mpabalwani et al. 1995 ; Steele et al. 1998 ) show that boys are more likely than girls to be taken to the facility because of diarrhea (boy-girl ratios are 2 to 1 and 4 to 1, respectively). However, nationally representative studies, such as the DHSs, conducted from 1987 to 2001 in several Sub-Saharan African countries show no significant sex differences for health care–seeking behavior and treatment received, whether it is given at home or at a health facility. Findings are summarized in table 9.8 .

Table 9.8. Children under Five Taken to Health Facilities or Receiving Treatment for Diarrheal Disease in the Two Weeks before Survey, by Sex (percent).

Children under Five Taken to Health Facilities or Receiving Treatment for Diarrheal Disease in the Two Weeks before Survey, by Sex (percent).

The African region has been a target of diarrheal epidemic outbreaks for several decades. One of the most dramatic manifestations of these outbreaks occurred in July 1994 among Rwandan refugees in Goma, Democratic Republic of Congo (formerly Zaire), when almost 50,000 refugees died during a diarrhea epidemic.

The African region has replaced the Indian subcontinent as the new home of V. cholerae. The seventh cholera pandemic that originated in Asia reached Africa in the early 1970s. In 2001 there were more than 170,000 reported cases of cholera, which represented 94 percent of the globally reported cases. From these, 2,590 people died. Nearly all countries in Sub-Saharan Africa now regularly report cases of cholera. Table 9.9 shows the reported number of cases and deaths from cholera in the world and in the African region between 1996 and 2001. These figures, however, need to be interpreted with caution, since countries that have endemic cholera appear not to have notified the WHO of any cases of cholera.

Table 9.9. Cases and Deaths Due to V. cholerae Reported to WHO, 1996–2001.

Cases and Deaths Due to V. cholerae Reported to WHO, 1996–2001.

Early reports of Vibrio parahaemolyticus in gastroenteritis cases in Africa ( Utsalo, Eko, and Antia-Obong 1991 ) have been confirmed to be associated with the O3:K6 pandemic strain ( Ansaruzzaman et al. 2004 ; Chowdhury et al. 2000 ), documenting the extension of this pandemic into the region. S. dysenteriae serotype 1 has also been documented to cause outbreaks of dysenteric diarrhea in several African countries ( Birmingham et al. 1997 ; Guerin et al. 2003 ; Malakooti et al. 1997 ), including in refugee camps ( Paquet et al. 1995 ). These organisms are important causes of morbidity and mortality in diarrhea outbreaks among stable communities and more so in displaced populations or those affected by catastrophic events. The widespread use of antibiotics across all regions has increased the prevalence of antibiotic resistance in most bacterial enteropathogens, increasing the risk in the region of an outbreak of S. dysenteriae serotype 1 with multiresistant strains.

  • The Role of Interventions to Control Diarrheal Diseases

There is sufficient evidence that several interventions are effective in the prevention and treatment of diarrheal diseases ( Jones et al. 2003 ). These interventions are exclusive breastfeeding, complementary feeding, safe water, good sanitation and hygiene, zinc and vitamin A supplementation, ORT, and antibiotics for dysentery. It is estimated that these interventions could prevent 22 percent of deaths due to diarrhea ( Jones et al. 2003 ). Most of these interventions are feasible for implementation in low-income countries such as those in the African region; however, the capacity to deliver these important interventions effectively should be strengthened ( Bryce et al. 2003 ). The availability of safe and effective rotavirus vaccines ( Ruiz-Palacios et al. 2006 ; Vesikari et al. 2006 ), introduced in several countries in Latin America in 2005 are likely to complement these interventions, if effectively delivered. However, the stability of diarrhea rates observed in all reviews done since the 1980s shows that despite the reduction of diarrhea mortality, most likely through better case management, very little has been done to prevent the transmission of diarrheal diseases. The progress toward better water and sanitation observed in other regions has not yielded a reduction of diarrhea morbidity, suggesting that poor hygiene practices ( Yeager et al. 1999 ) and the ingestion of contaminated food ( Lanata 2003 ) may be the most important factors and where preventive interventions, like handwashing ( Curtis and Cairncross 2003 ), should be promoted.

Despite data limitations in estimating accurate numbers of diarrhea cases and deaths, it becomes clear from the results of this and other reviews that diarrheal disease remains an important cause of morbidity and mortality among children under five years of age in the African region. As opposed to the declining trends in the proportion of diarrhea mortality in other developing regions of the world, virtually no decline has been observed in the African region since the early 1980s. Diarrheal diseases remain one of the major killers of children under five, being responsible for about 750,000 of a total of 4.3 million deaths of African children up to four years of age.

More important than the precision in the numbers and in the exact contribution of each pathogen to diarrhea morbidity and mortality are the patterns and trends shown in this review. The fact that almost 40 percent of all diarrhea deaths in children under five worldwide occur in the African region is striking. The diarrhea mortality burden among children under five in Sub-Saharan Africa reveals the persistent magnitude of this preventable and treatable disease in the region.

The efficacy of existing interventions to prevent or treat diarrheal diseases and to thereby reduce diarrhea mortality has been proved. Large reductions in child mortality could be achieved with their implementation. Therefore, careful planning and evaluation of interventions to control cases and deaths due to diarrhea will be important if under-five mortality is to be reduced and goal four of the Millennium Development Goals—to reduce under-five mortality by two-thirds by 2015, from the base year 1990 ( United Nations 2000 )—is to be achieved in the African region.

  • Akinyemi K. O., Oyefolu A. O., Opere B., Otunba-Payne V. A., Oworu A. O. Escherichia Coli in Patients with Acute Gastroenteritis in Lagos, Nigeria. East African Medical Journal. 1998; 75 :512–15. [ PubMed : 10493052 ]
  • Amin R. Immunization Coverage and Child Mortality in Two Rural Districts of Sierra Leone. Social Science and Medicine. 1996; 42 :1599–1604. [ PubMed : 8771643 ]
  • Ansaruzzaman M., Bhuiyan N. A., Nair G. B., Sack D. A., Lucas M., Deen J. L., Ampuero J., Chaignat C. L. The Mozambique Cholera Vaccine Demonstration Project Coordination Group. "Cholera in Mozambique, Variant of Vibrio cholerae ". Emerging Infectious Diseases. 2004; 10 :2057–59. [ PMC free article : PMC3329043 ] [ PubMed : 16010751 ]
  • Armah G. E., Mingle J. A. A., Dodoo A. K., Anyanful A., Antwi R., Commey J., Nkrumah F. K. Seasonality of Rotavirus Infections in Ghana. Annals of Tropical Paediatrics. 1994; 14 :223–30. [ PubMed : 7825996 ]
  • Audu R., Omilabu S. A., de Beer M., Peenze I., Steele A. D. Diversity of Human Rotavirus VP6, VP7, and VP4 in Lagos State, Nigeria. Journal of Health, Population, and Nutrition. 2002; 20 :59–64. [ PubMed : 12022161 ]
  • Baltazar J. C., Nadera D. P., Victora C. G. Evaluation of the National Control of Diarrhoeal Disease Programme in the Philippines, 1980–93. Bulletin of the World Health Organization. 2002; 80 :637–43. [ PMC free article : PMC2567577 ] [ PubMed : 12219155 ]
  • Becker S. R., Diop F., Thornton J. N. Infant and Child Mortality Estimates in Two Counties of Liberia; Results of a Survey in 1988 and Trends Since 1984. International Journal of Epidemiology. 1993; 22 (Suppl. 1):S56–63. [ PubMed : 8307676 ]
  • Bendib A., Dekkar N., Lamdjadani N. Facteurs associés à la mortalité juvénile, infantile et néonatale. Résultats d'une enquête nationale en Algérie. Archives Françaises de Pediatrie. 1993; 50 :741–47. [ PubMed : 8060202 ]
  • Bern, C., and R. I. Glass. 1994. "Impact of Diarrheal Diseases Worldwide." In Viral Infections of the Gastrointestinal Tract, 2nd ed., ed. A. Z. Kapikian. New York: Marcel Dekker.
  • Bern C., Martines J., de Zoysa I., Glass R. I. The Magnitude of the Global Problem of Diarrhoeal Disease: A Ten-Year Update. Bulletin of the World Health Organization. 1992; 70 :705–14. [ PMC free article : PMC2393403 ] [ PubMed : 1486666 ]
  • Birmingham M. E., Lee L. A., Ntakibirora M., Bizimana F., Deming M. S. A Household Survey of Dysentery in Burundi: Implications for the Current Pandemic in Sub-Saharan Africa. Bulletin of the World Health Organization. 1997; 75 :45–53. [ PMC free article : PMC2486987 ] [ PubMed : 9141750 ]
  • Bishop, R. 1994. "Natural History of Human Rotavirus Infection." In Viral Infections of the Gastrointestinal Tract , 2nd ed., ed. A. Z. Kapikian. New York: Marcel Dekker.
  • Boerma J. T., Black R. E., Sommerfelt A. E., Rustein S. O., Bicego G. T. Accuracy and Completeness of Mothers' Recall of Diarrhoea Occurrence in Pre-School Children in Demographic and Health Surveys. International Journal of Epidemiology. 1991; 20 :1073–80. [ PubMed : 1800406 ]
  • Bradley A. K., Gilles H. M. Pointers to Causes of Death in the Malumfashi Area, Northern Nigeria. Annals of Tropical Medicine and Parasitology. 1984; 78 :265–71. [ PubMed : 6486932 ]
  • Bryce J., Boschi-Pinto C., Shibuya K., Black R. E. the Child Health Epidemiology Reference Group. WHO Estimates of the Causes of Death in Children. Lancet. 2005; 365 :1147–52. [ PubMed : 15794969 ]
  • Bryce J., el Arifeen S., Pariyo G., Lanata C., Gwatkin D., Habicht J. P. Multi-Country Evaluation of IMCI Study Group. "Reducing Child Mortality: Can Public Health Deliver? Lancet. 2003; 362 :159–64. [ PubMed : 12867119 ]
  • Cassel-Beraud A. M., Michel P., Garbarg-Chenon A. Epidemiological Study of Infantile Rotavirus Diarrhea in Tananarive (Madagascar). Journal of Diarrhoeal Diseases Research. 1993; 11 :82–87. [ PubMed : 8409286 ]
  • Chowdhury N. R., Chakraborty S., Ramamurthy T., Nishibuchi M., Yamasaki S., Takeda Y., Nair G. B. Molecular Evidence of Clonal Vibrio Parahaemolyticus Pandemic Strains. Emerging Infectious Diseases. 2000; 6 :631–36. [ PMC free article : PMC2640929 ] [ PubMed : 11076722 ]
  • Chunge R. N., Wamola I. A., Kinoti S. N., Muttunga J., Mutanda L. N., Nagelkerke N., Muthami L., Muniu E., Simwa J. M., Karumba P. N., Kabiru P. Mixed Infections in Childhood Diarrhoea: Results of a Community Study in Kiambu District, Kenya. East African Medical Journal. 1989; 66 :715–23. [ PubMed : 2606013 ]
  • Curtis V., Cairncross S. Effect of Washing Hands with Soap on Diarrhoea Risk in the Community: A Systematic Review. Lancet Infectious Diseases. 2003; 3 :275–81. [ PubMed : 12726975 ]
  • Dabis F., Ekpini E. R. HIV-1/AIDS and Maternal and Child Health in Africa. Lancet. 2002; 359 :2097–104. [ PubMed : 12086778 ]
  • Daniels D. L., Cousens S. N., Makoae L. N., Feachem R. G. A Case-Control Study of the Impact of Improved Sanitation on Diarrhea Morbidity in Lesotho. Bulletin of the World Health Organization. 1990; 68 :455–63. [ PMC free article : PMC2393155 ] [ PubMed : 2208559 ]
  • De Francisco A., Hall A. J., Schellenberg J. R., Greenwood A. M., Greenwood B. M. The Pattern of Infant and Childhood Mortality in Upper River Division, The Gambia. Annals of Tropical Paediatrics. 1993; 13 :345–52. [ PubMed : 7506881 ]
  • Delacollette C., Barutwanayo M. Mortalité et morbidité aux jeunes âges dans une région à paludisme hyperendémique stable, commune de Nyanza-Lac, Imbo Sud, Burundi. Bulletin de la Societé de Pathologie Exotique. 1993; 86 :373–79. [ PubMed : 8124110 ]
  • Delacollette C., Van der Stuyft P., Molima K., Delacollette-Lebrun C., Wery M. Étude de la mortalité globale et de la mortalité liée au paludisme dans le Kivu montagneux, Zaire. Revue d' Epidémiologie et de Santé Publique. 1989; 37 :161–66. [ PubMed : 2772361 ]
  • Ekanem E. E., Asindi A. A., Okoi O. U. Community-Based Surveillance of Paediatric Deaths in Cross River State, Nigeria. Tropical and Geographical Medicine. 1994; 46 :305–8. [ PubMed : 7855918 ]
  • Fisher T. K., Steinsland H., Mølbak K., Ca R., Gentsch J. R., Valentiner-Branth P., Aaby P., Sommerfelt H. Genotype Profiles of Rotavirus Strains from Children in a Suburban Community in Guinea-Bissau, Western Africa. Journal of Clinical Microbiology. 2000; 38 :264–67. [ PMC free article : PMC88706 ] [ PubMed : 10618098 ]
  • Fontaine O., Diop B., Beau J. P., Briend A., Ndiaye M. La diarrhée infantile au Senegal. Médecine Tropicale: Revue du Corps de Santé Colonial. 1984; 44 :27–31. [ PubMed : 6738335 ]
  • Gedlu E., Aseffa A. Campylobacter Enteritis among Children in North-West Ethiopia: A 1-Year Prospective Study. Annals of Tropical Paediatrics. 1996; 16 :207–12. [ PubMed : 8893950 ]
  • Georges M. C., Roure C., Tauxe R. V., Meunier D. M. Y., Merlin M., Testa J., Baya C., Limbassa J., Georges A. J. Diarrheal Morbidity and Mortality in Children in the Central African Republic. American Journal of Tropical Medicine and Hygiene. 1987; 36 :598–602. [ PubMed : 3578657 ]
  • Georges-Courbot M. C., Beraud-Cassel A. M., Gouandjika I., Georges A. J. Prospective Study of Enteric Campylobacter Infections in Children from Birth to Six Months in the Central African Republic. Journal of Clinical Microbiology. 1987; 25 :836–39. [ PMC free article : PMC266099 ] [ PubMed : 3584419 ]
  • Georges-Coubot M. C., Cassel-Beraud A. M., Gouandjika I., Monges J., Georges A. J. A Cohort Study of Enteric Campylobacter Infection in Children from Birth to Two Years in Bangui (Central African Republic). Transactions of the Royal Society of Tropical Medicine and Hygiene. 1990; 84 :122–25. [ PubMed : 2345912 ]
  • Georges-Courbot M. C., Monges J., Beraud-Cassel A. M., Gouandjika I., Georges A. J. Prospective Longitudinal Study of Rotavirus Infections in Children from Birth to Two Years of Age in Central Africa. Annales de l'Institut Pasteur. Virology. 1988; 139 :421–28. [ PubMed : 3214595 ]
  • Gomwalk N. E., Gosham L. T., Umoh U. J. Rotavirus Gastroenteritis in Pediatric Diarrhea in Jos, Nigeria. Journal of Tropical Pediatrics. 1990; 36 :52–55. [ PubMed : 2162394 ]
  • Gomwalk N. E., Umoh U. J., Gosham L. T., Ahmad A. A. Influence of Climatic Factors on Rotavirus Infection among Children with Acute Gastroenteritis in Zaria, Northern Nigeria. Journal of Tropical Pediatrics. 1993; 39 :293–97. [ PubMed : 8271337 ]
  • Greenwood B. M., Bradley A. K., Byass P., Greenwood A. M., Menon A., Snow R. W., Hayes R. J., Hatib-N'Jie A. B. Evaluation of a Primary Health Care Programme in The Gambia. II. Its Impact on Mortality and Morbidity in Young Children. Journal of Tropical Medicine and Hygiene. 1990; 93 :87–97. [ PubMed : 2325198 ]
  • Greenwood B. M., Greenwood A. M., Bradley S., Tulloch S., Hayes R., Oldfield F. S. J. Deaths in Infancy and Early Childhood in a Well-Vaccinated, Rural, West African Population. Annals of Tropical Paediatrics. 1987; 7 :91–99. [ PubMed : 2441658 ]
  • Griffiths F. H., Steele A. D., Alexander J. J. The Molecular Epidemiology of Rotavirus-Associated Gastro-Enteritis in the Transkei, Southern Africa. Annals of Tropical Paediatrics. 1992; 12 :259–64. [ PubMed : 1280040 ]
  • Guerin P. J., Brasher C., Baron E., Mic D., Grimont F., Ryan M., Aavitsland P., Legros D. Shigella Dysenteriae Serotype 1 in West Africa: Intervention Strategy for an Outbreak in Sierra Leone. Lancet. 2003; 362 :705–6. [ PubMed : 12957094 ]
  • Haffejee I. E. The Epidemiology of Rotavirus Infections: A Global Perspective. Journal of Pediatric Gastroenterology and Nutrition. 1995; 20 :275–86. [ PubMed : 7608822 ]
  • Haggerty P. A., Muladi K., Kirkwood B. R., Ashworth A., Manunebo M. Community-Based Hygiene Education to Reduce Diarrhoeal Disease in Rural Zaire: Impact of the Intervention on Diarrhoeal Morbidity. International Journal of Epidemiolology. 1994; 23 :1050–59. [ PubMed : 7860156 ]
  • Helen Keller International. 1994. "Summary Report on the Nutritional Impact of Sex-biased Behavior." Nutritional Surveillance Project, Dhaka, Bangladesh.
  • Hodges M., Williams R. A. M. Registered Infant and UnderFive Deaths in Freetown, Siera Leone from 1987–1991 and a Comparison with 1969–1979. West African Journal of Medicine. 1998; 17 :95–98. [ PubMed : 9715114 ]
  • Jaffar S., Leach A., Greenwood A. M., Jepson A., Muller O., Ota M. O. C., Bojang K., Obaro S., Greenwood B. M. Changes in the Pattern of Infant and Childhood Mortality in Upper River Division, The Gambia, from 1989 to 1993. Tropical Medicine & International Health. 1997; 2 :28–37. [ PubMed : 9018300 ]
  • Jamison, D. T., H. W. Mosley, A. R. Measham, and J. L. Bobadilla. 1993. Disease Control Priorities in Developing Countries . New York: Oxford University Press.
  • Jinadu M. K., Olusi S. O., Agun J. I., Fabiyi A. K. Childhood Diarrhea in Rural Nigeria. I. Studies on Prevalence, Mortality and Socio-Environmental Factors. Journal of Diarrhoeal Diseases Research. 1991; 9 :323–27. [ PubMed : 1800564 ]
  • Jones G., Steketee R. W., Black R. E., Bhutta Z. A., Morris S. S. the Bellagio Child Survival Study. How Many Child Deaths Can We Prevent This Year? Lancet. 2003; 362 :65–71. [ PubMed : 12853204 ]
  • Kahn K., Tollman S. M., Garenne M., Gear J. S. Who Dies from What? Determining Cause of Death in South Africa's Rural NorthEast. Tropical Medicine & International Health. 1999; 4 :433–41. [ PubMed : 10444319 ]
  • Kalter H. D., Gray R. H., Black R. E. Validation of Postmortem Interviews to Ascertain Selected Causes of Death in Children. International Journal of Epidemiology. 1990; 19 :380–86. [ PubMed : 2376451 ]
  • Kirkwood, B. 1991. "Diarrhea." In Disease and Mortality in Sub-Saharan Africa, ed. R. G. Feachem and D. T. Jamison, 134–57. New York: Oxford University Press.
  • Kosek M., Bern C., Guerrant R. The Global Burden of Diarrheal Disease, As Estimated from Studies Published Between 1992 and 2000. Bulletin of the World Health Organization. 2003; 81 :197–204. [ PMC free article : PMC2572419 ] [ PubMed : 12764516 ]
  • Koulla-Shiro S., Loe C., Ekoe T. Prevalence of Campylobacter Enteritis in Children from Yaounde (Cameroon). Central African Journal of Medicine. 1995; 4 :91–94. [ PubMed : 7788677 ]
  • LaFond, A. K. 1995. "A Review of Sanitation Program Evaluation in Developing Countries." Activity Report 5, Environmental Health Project, Arlington, VA.
  • Lanata C. F. Studies of Food Hygiene and Diarrhoeal Disease. International Journal of Environmental Health Research. 2003; 13 :S175–83. [ PubMed : 12775394 ]
  • League of Nations, Health Section of the Secretariat. 1996–2002. Weekly Epidemiological Record, vols 71–77. http://www ​.who.int/wer/archives/en/
  • MacDougall, J., and C. McGahey. 2003. "Three Community-Based Environmental Sanitation and Hygiene Projects Conducted in the Democratic Republic of Congo." Activity Report 119, USAID, New York.
  • Malakooti M. A., Alaii J., Shanks G. D., Phillips-Howard P. A. Epidemic Dysentery in Western Kenya. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1997; 91 :541–43. [ PubMed : 9463662 ]
  • Manun'ebo M. N., Haggerty P. A., Kalengaie M., Ashworth A., Kirkwood B. R. Influence of Demographic, Socioeconomic and Environmental Variables on Childhood Diarrhea in a Rural Area of Zaire. Journal of Tropical Medicine and Hygiene. 1994; 97 (1):31–38. [ PubMed : 8107171 ]
  • Mathers, C. D., C. Stein, D. Ma Fat, C. Rao, M. Inoue, N. Tomijima, C. Bernard, A. Lopez, and C. J. L. Murray. 2002. "Global Burden of Disease 2000: Version 2 Methods and Results." Global Programme on Evidence for Health Policy Discussion Paper 50, WHO, Geneva.
  • Miller P., Hirschhorn N. The Effect of a National Control of Diarrheal Diseases Program on Mortality: The Case of Egypt. Social Science and Medicine. 1995; 40 :S1–30. [ PubMed : 7638641 ]
  • Mirza N. M., Caulfield L. E., Black R. E., Macharia W. M. Risk Factors for Diarrheal Duration. American Journal of Epidemiology. 1997; 146 (9):776–85. [ PubMed : 9366626 ]
  • Mnisi Y. N., Williams M. M., Steele A. D. Subgroup and Serotype Epidemiology of Human Rotaviruses Recovered at Ga-Rankuwa, Southern Africa. Central African Journal of Medicine. 1992; 38 :221–25. [ PubMed : 1327535 ]
  • Mobley C. C., Boerma J. T., Titus S., Lohrke B., Shangula K., Black R. E. Validation Study of a Verbal Autopsy Method for Causes of Childhood Mortality in Namibia. Journal of Tropical Pediatrics. 1996; 42 :365–69. [ PubMed : 9009566 ]
  • Mølbak K., Aaby P., Ingholt L., Hojlyng N., Gottschau A., Andersen H. Persistent and Acute Diarrhea as the Leading Causes of Child Mortality in Urban Guinea-Bissau. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1992; 86 :216–20. [ PubMed : 1440794 ]
  • Mølbak K., Hojlyng N., Ingholt L., Da Silva A. P., Jepsen S., Aaby P. An Epidemic Outbreak of Cryptosporidiosis: A Prospective Community Study from Guinea Bissau. Pediatric Infectious Disease Journal. 1990; 9 :566–70. [ PubMed : 2235172 ]
  • Mølbak K., Jensen H., Ingholt L., Aaby P. Risk Factors for Diarrheal Disease Incidence in Early Childhood: A Community Cohort Study from Guinea-Bissau. American Journal of Epidemiology. 1997; 146 :273–82. [ PubMed : 9247012 ]
  • Mølbak K., Wested N., Hojlyng N., Scheutz F., Gottschau A., Aaby P., da Silva A. P. J. The Etiology of Early Childhood Diarrhea: A Community Study from Guinea-Bissau. Journal of Infectious Disease. 1994; 169 :581–87. [ PubMed : 8158030 ]
  • Morris S. S., Black R. E., Tomaskovic L. Predicting the Distribution of Under-Five Deaths by Cause in Countries without Adequate Vital Registration Systems. International Journal of Epidemiology. 2003; 32 :1041–51. [ PubMed : 14681271 ]
  • Moy R. J., Booth I. W., Choto R. G., McNeish A. S. Recurrent and Persistent Diarrhea in a Rural Zimbabwean Community: A Prospective Study. Journal of Tropical Pediatrics. 1991; 37 :293–99. [ PubMed : 1791647 ]
  • Mpabalwani M., Oshitani H., Kasolo F., Mizuta K., Luo N., Matsubayashi N., Bhat G., Suzuki H., Numazaki Y. Rotavirus Gastro-Enteritis in Hospitalized Children with Acute Diarrhea in Zambia. Annals of Tropical Paediatrics. 1995; 15 :39–43. [ PubMed : 7598436 ]
  • Mtango F. D. E., Neuvians D. Acute Respiratory Infections in Children under Five Years. Control Project in Bagamoyo District, Tanzania. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1986; 80 :851–58. [ PubMed : 3603635 ]
  • Mtango F. D. E., Neuvians D., Broome C. V., Hightower A. W., Pio A. Risk Factors for Deaths in Children under 5 Years Old in Bangamoyo District, Tanzania. Tropical Medicine and Parasitology. 1992; 43 :229–33. [ PubMed : 1293726 ]
  • Mutanda L. N., Gemert W., Kangethe S. K., Juma R. Seasonal Pattern of Some Causative Agents of Childhood Diarrhoea in Nairobi. East African Medical Journal. 1986; 63 :373–81. [ PubMed : 3769845 ]
  • Mutanda L. N., Kangethe S. K., Juma R., Lichenga E. O., Gathecha C. Aetiology of Diarrhoea in Malnourished Children at Kenyatta National Hospital. East African Medical Journal. 1985; 62 :835–42. [ PubMed : 3835063 ]
  • Nakano T., Binka F. N., Afari E. A., Agbodaze D., Aryeetey M. E., Mingle J. A. A., Kamiya H., Sakurai M. Survey of Enteropathogenic Agents in Children with and without Diarrhoea in Ghana. Journal of Tropical Medicine and Hygiene. 1990; 93 :408–12. [ PubMed : 2270006 ]
  • Nakata S., Gatheru Z., Ukae S., Adachi N., Kobayashi N., Honma S., Muli J., Nyangao J., Kiplagat E., Tukei P. M., Chiba S. Epidemiological Study of the G Serotype Distribution of Group A Rotavirus in Kenya from 1991 to 1994. Journal of Medical Virology. 1999; 58 :296–303. [ PubMed : 10447427 ]
  • Obi C. L., Coker A. O., Epoke J., Ndip R. N. Enteric Bacterial Pathogens in Stools of Residents of Urban and Rural Regions in Nigeria: A Comparison of Patients with and without Diarrhoea and Controls without Diarrhoea. Journal of Diarrhoeal Diseases Research. 1997; 15 :241–47. [ PubMed : 9661320 ]
  • Okeke I. N., Lamikanra A., Steinrück H., Kaper J. K. Characterization of Escherichia Coli Strains from Cases of Childhood Diarrhea in Provincial Southwestern Nigeria. Journal of Clinical Microbiology. 2000; 38 :7–12. [ PMC free article : PMC86005 ] [ PubMed : 10618054 ]
  • Omondi-Odhiambo J., Ginneken K., Voorhoeve A. M. Mortality by Cause of Death in a Rural Area of Machakos District, Kenya in 1975–78. Journal of Biosocial Science. 1990; 22 :63–75. [ PubMed : 2298762 ]
  • Oni G. A., Schumann D. A., Oke E. A. Diarrheal Disease Morbidity, Risk Factors and Treatments in a Low Socioeconomic Area of Ilorin, Kwara State, Nigeria. Journal of Diarrhoeal Diseases Research. 1991; 9 :250–57. [ PubMed : 1787281 ]
  • Paquet C., Leborgne P., Sasse A., Varaine F. An Outbreak of Shigella Dysenteriae Type 1 Dysentery in a Refugee Camp in Rwanda. Santé 1995; 5 :181–84. [ PubMed : 7640901 ]
  • Pennap G., Pager C. T., Peenze I., de Beer M. C., Kwaga J. K. P., Ogalla W. N., Umoh J. U., Steele A. D. Epidemiology of Astrovirus Infection in Zaria, Nigeria. Journal of Tropical Pediatrics. 2002; 48 :98–101. [ PubMed : 12022437 ]
  • Pennap G., Peenze I., de Beer M., Pager C. T., Kwaga J. K. P., Ogalla W. N., Umoh J. U., Steele D. VP6 Subgroup and VP7 Serotype of Human Rotavirus in Zaria, Northern Nigeria. Journal of Tropical Pediatrics. 2000; 46 :344–47. [ PubMed : 11191145 ]
  • Perch M., Sodemann Jakobsen M. S., Vallentiner-Branth P., Steinland H., Fisher T. K., Duarte L. D., Aaby P., Mølbak K. Seven Years' Experience with Cryptosporidium parvum in Guinea-Bissau, West Africa. Annals of Tropical Paediatrics. 2001; 21 :313–18. [ PubMed : 11732149 ]
  • Pison G., Trape J. F., Lefebvre M., Enel C. Rapid Decline in Child Mortality in a Rural Area of Senegal. International Journal of Epidemiology. 1993; 22 (1):72–80. [ PubMed : 8449650 ]
  • Rowland S. G. J., Lloyd-Evans N., Williams K., Rowland M. G. M. The Etiology of Diarrhea Studied in the Community in Young Urban Gambian Children. Journal of Diarrhoeal Diseases Research. 1985; 3 :7–13. [ PubMed : 2989356 ]
  • Ruiz-Palacios G. M., Perez-Schael I., Velazquez R., Abate H., Breuer T., Costa-Clemens S. A., Cheuvart B. et al. Safety and Efficacy of an Attenuated Vaccine against Severe Rotavirus Gastroenteritis. New England Journal of Medicine. 2006; 354 :11–22. [ PubMed : 16394298 ]
  • Saidi S. M., Iijima Y., Sang W. K., Mwangudza A. K., Oundo J. O., Taga K., Aihara M., Nagayama K., Yamamoto H., Waiyaki P. G., Honda T. Epidemiological Study on Infectious Diarrhoeal Diseases in Children in a Coastal Rural Area of Kenya. Microbiology and Immunology. 1997; 41 :773–78. [ PubMed : 9403500 ]
  • Sebata T., Steele D. Atypical Rotavirus Identified from Young Children with Diarrhea in South Africa. Journal of Health, Population, and Nutrition. 2001; 19 :199–203. [ PubMed : 11761774 ]
  • Shamebo D., Muhe L., Sandstrom A., Wall S. The Butajira Rural Health Project in Ethiopia: Mortality Pattern of the Under Fives. Journal of Tropical Pediatrics. 1991; 37 :254–61. [ PubMed : 1784061 ]
  • Snow R. W., Armstrong J. R., Forster D., Winstanley M. T., Marsh V. M., Newton C. R., Waruiru C., Mwangi I., Winstanley P. A., Marsh K. Childhood Deaths in Africa: Uses and Limitations of Verbal Autopsies. Lancet. 1992; 340 :351–55. [ PubMed : 1353814 ]
  • Snow R. W., Bast de Azevedo I., Forster D., Mwankuyse S., Bomu G., Kassiga G., Nyamawi C., Teuscher T., Marsh K. Maternal Recall of Symptoms Associated with Childhood Deaths in Rural East Africa. International Journal of Epidemiology. 1993; 22 :677–83. [ PubMed : 8225743 ]
  • Snyder J. D., Merson M. H. The Magnitude of the Global Problem of Acute Diarrheal Disease: A Review of Active Surveillance Data. Bulletin of the World Health Organization. 1982; 60 :605–13. [ PMC free article : PMC2536091 ] [ PubMed : 6982783 ]
  • Steele A. D., Basetse H. R., Blacklow N. R., Herrmann J. E. Astrovirus Infection in South Africa: A Pilot Study. Annals of Tropical Paediatrics. 1998; 18 :315–19. [ PubMed : 9924588 ]
  • Steele A. D., Geyer A., Alexander J. J., Crewe-Brown H. H., Fripp P. J. Enteropathogens Isolated from Children with Gastro-Enteritis at Ga-Rankuwa Hospital, South Africa. Annals of Tropical Paediatrics. 1988; 8 :262–67. [ PubMed : 2467616 ]
  • Sundary, R. 1986. "Health Implications of Sex Discrimination in Childhood: A Review Paper and an Annotated Bibliography." WHO/UNICEF/FHE 86.2, WHO, Geneva.
  • Tswana S. A., Jorgensen P. H., Halliwell R. W., Kapaata R., Moyo S. R. The Incidence of Rotavirus Infection in Children from Two Selected Study Areas in Zimbabwe. Central African Journal of Medicine. 1990; 36 :241–46. [ PubMed : 2092874 ]
  • United Nations. 2000. United Nations Millennium Declaration. General Assembly resolution 55/2, United Nations, New York. http://www ​.un.org/millennium ​/declaration/ares552e.pdf .
  • Utsalo S. J., Eko F. O., Antia-Obong O. E. Cholera and Vibrio parahaemolyticus Diarrhoea Endemicity in Calabar, Nigeria. West African Journal of Medicine. 1991; 10 :175–80. [ PubMed : 1911487 ]
  • Vaahtera M., Kulmala T., Maleta K., Cullinan T., Salin M.-L., Ashorn P. Epidemiology and Predictors of Infant Morbidity in Rural Malawi. Paediatric and Perinatal Epidemiology. 2000; 14 :363–71. [ PubMed : 11101024 ]
  • Vesikari T., Matson D. O., Dennehy P., Van Damme P., Santosham M., Rodriguez Z., Dallas M. J. et al. Safety and Efficacy of a Pentavalent Human-Bovine (WC3) Reassortant Rotavirus Vaccine. New England Journal of Medicine. 2006; 354 :23–33. [ PubMed : 16394299 ]
  • Victora C. G., Bryce J., Fontaine O., Monasch R. Reducing Deaths from Diarrhea Through Oral Rehydration Therapy. Bulletin of the World Health Organization. 2000; 78 :1246–55. [ PMC free article : PMC2560623 ] [ PubMed : 11100619 ]
  • Victora C. G., Huttly S. R., Fuchs S. C., Barros F. C., Garenne M., Leroy O., Fontaine O., Beau J. P., Fauveau V., Chowdury H. R. International Differences in Clinical Patterns of Diarrheal Deaths: A Comparison of Children from Brazil, Senegal, Bangladesh, and India. Journal of Diarrhoeal Diseases Research. 1993; 11 (1):25–29. [ PubMed : 8315250 ]
  • Victora C. G., Olinto M. T., Barros F. C., Nobre L. C. Falling Diarrhea Mortality in Northeastern Brazil: Did ORT Play a Role? Health Policy and Planning. 1996; 11 :132–41. [ PubMed : 10158455 ]
  • Victora C. G., Wagstaff A., Schellenberg J. A., Gwatkin D., Claeson M., Habicht J.-P. Applying an Equity Lens to Child Health Mortality: More of the Same Is Not Enough. Lancet. 2003; 362 :233–41. [ PubMed : 12885488 ]
  • Walker N., Schwartländer B., Bryce J. Meeting International Goals in Child Survival and HIV/AIDS. Lancet. 2002; 360 :284–89. [ PubMed : 12147371 ]
  • Watts T., Ng'andu N., Wray J. Children in an Urban Township in Zambia. A Prospective Study of Children during Their First Year of Life. Journal of Tropical Pediatrics. 1990; 36 :287–93. [ PubMed : 2280435 ]
  • WHO (World Health Organization). 2000. WHO-UNICEF-WSSCC Global Water Supply and Sanitation Assessment 2000 Report . Geneva: WHO.
  • ———. 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva, WHO. [ PubMed : 14741909 ]
  • ———. 2005. "Mothers and Children Matter—So Does Their Health." In The World Health Report 2005 — Make Every Mother and Child Count . Geneva: WHO.
  • Yeager B. A., Huttly S. R., Bartolini R., Rojas M., Lanata C. F. Defecation Practices of Young Children in a Peruvian Shanty Town. Social Science and Medicine. 1999; 49 :531–41. [ PubMed : 10414812 ]
  • Cite this Page Boschi-Pinto C, Lanata CF, Mendoza W, et al. Diarrheal Diseases. In: Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and Mortality in Sub-Saharan Africa. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 9.
  • PDF version of this title (5.0M)

In this Page

Related information.

  • PMC PubMed Central citations
  • PubMed Links to PubMed

Similar articles in PubMed

  • [Infant and child morbidity and mortality due to diarrheal disease in central Africa]. [Ann IFORD. 1988] [Infant and child morbidity and mortality due to diarrheal disease in central Africa]. Keuzeta JJ, Merlin M, Josse R, Mouanda V, Kouka Bemba D. Ann IFORD. 1988 Jun; 12(1):69-87.
  • Review The magnitude of the global problem of diarrhoeal disease: a ten-year update. [Bull World Health Organ. 1992] Review The magnitude of the global problem of diarrhoeal disease: a ten-year update. Bern C, Martines J, de Zoysa I, Glass RI. Bull World Health Organ. 1992; 70(6):705-14.
  • Review The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. [Bull World Health Organ. 2003] Review The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Kosek M, Bern C, Guerrant RL. Bull World Health Organ. 2003; 81(3):197-204. Epub 2003 May 16.
  • Review Diagnosis and Treatment of the Febrile Child. [Reproductive, Maternal, Newbor...] Review Diagnosis and Treatment of the Febrile Child. Herlihy JM, D’Acremont V, Hay Burgess DC, Hamer DH. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third Edition (Volume 2). 2016 Apr 5
  • The magnitude of the global problem of acute diarrhoeal disease: a review of active surveillance data. [Bull World Health Organ. 1982] The magnitude of the global problem of acute diarrhoeal disease: a review of active surveillance data. Snyder JD, Merson MH. Bull World Health Organ. 1982; 60(4):605-13.

Recent Activity

  • Diarrheal Diseases - Disease and Mortality in Sub-Saharan Africa Diarrheal Diseases - Disease and Mortality in Sub-Saharan Africa

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

statistics

IMAGES

  1. (PDF) Promoting Appropriate Management of Diarrhea A Systematic Review

    literature review of diarrhea

  2. (PDF) Probiotics for the Prevention and Treatment of Antibiotic

    literature review of diarrhea

  3. (PDF) Antibiotic-associated diarrhea: Epidemiology, trends and treatment

    literature review of diarrhea

  4. (PDF) Severe Diarrhea in a 4-Month-Old Baby Girl with Acute

    literature review of diarrhea

  5. (PDF) Diarrhea Disease among Children under 5 Years of Age: A Global

    literature review of diarrhea

  6. (PDF) Review: Chronic and persistent diarrhea with a focus in the

    literature review of diarrhea

VIDEO

  1. علاج الأسهال عند الأطفال

  2. Diarrhoa

  3. These 10 Medications Give You Diarrhea

  4. علاج الاسهال عند الطيور بسرعة

  5. imodium(anti diarrhea)uses, side effect, action full review in hindi/urdu

  6. Recada Sachet Uses |Recada Sachet For Diarrhea Review

COMMENTS

  1. Diarrhea

    The normal value of water content in stools is approximately 10 mL/kg/day in infants and young children or 200 g/day in teenagers and adults. Diarrhea is the augmentation of water content in stools because of an imbalance in the normal functioning of physiologic processes of the small and large intestine responsible for the absorption of various ions, other substrates, and consequently water.

  2. Systematic review of diarrhea duration and severity in children and

    Diarrhea is a leading cause of morbidity and mortality across all age groups and regions of the world. Among children 0-59 months of age, diarrhea is responsible for 1.236 million deaths annually and is the second leading cause of death in this age group [].Though mortality rates among older children, adolescents, and adults are lower than those observed in children under five, diarrhea still ...

  3. Chronic Diarrhea in Adults: Evaluation and Differential Diagnosis

    Chronic diarrhea is defined as a predominantly loose stool lasting longer than four weeks. A patient history and physical examination with a complete blood count, C-reactive protein, anti-tissue ...

  4. A practical approach to the patient with chronic diarrhoea

    Introduction. Chronic diarrhoea is a common reason for consultation in general practice and secondary care. Studies have estimated a prevalence of up to 5% in a western population. 1 It can be defined as the passage of loose or watery stool (type 5-7 on the Bristol stool chart) with increased frequency, persisting for more than 4 weeks.

  5. Acute Infectious Diarrhea in Immunocompetent Adults

    Diarrhea is generally defined as the passage of three or more unformed stools per day, often in addition to other enteric symptoms, or the passage of more than 250 g of unformed stool per day. On ...

  6. Acute diarrhea: a practical review

    Abstract. This review provides a practical, simple, and logical approach to the diagnosis and management of patients with acute infectious diarrhea, one of the most common diagnoses in clinical practice. Diarrhea in the immunocompromised host, traveler's diarrhea, and diarrhea in the hospitalized patient are also discussed.

  7. Etiology of Diarrhea in Older Children, Adolescents and Adults ...

    Author Summary Diarrhea is an important cause of illness and death around the world and among people of all ages, but unfortunately we often do not know what specific bacterium or virus causes the illness. We conducted a review of the scientific literature with the goal of finding published studies that identified bacteria and viruses among patients with diarrhea in the community and in ...

  8. Diarrhea Disease among Children under 5 Years of Age: A Global

    the results of a study done in Dale district in Ethiopia repor ted that, the odds of. having diarrhea diseases among ch ildren under the age of 5 years were 3. 23. times higher among children from ...

  9. Etiology of Diarrhea in Older Children, Adolescents and Adults: A

    Abstract. Background: Diarrhea is an important cause of morbidity and mortality in all regions of the world and among all ages, yet little is known about the fraction of diarrhea episodes and deaths due to each pathogen. Methodology/Principal Findings: We conducted a systematic literature review to identify all papers reporting the proportion ...

  10. Approach to the adult patient with chronic diarrhea: A literature review

    Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or ...

  11. Acute Infectious Diarrhea

    Thorough clinical evaluation of a patient who presents with acute diarrhea is essential in order to guide a cost-effective, evidence-based approach to initial diagnostic testing and therapy. In ...

  12. Etiological, epidemiological, and clinical features of acute diarrhea

    Diarrhea remains one of the major causes of disease burden worldwide, despite significant progress in sanitation status and public health awareness 1,2,3.More than 4.4 billion cases and 1.6 ...

  13. Promoting appropriate management of diarrhea: a systematic review of

    Background: Scaling up of evidence-based management and prevention of childhood diarrhea is a public health priority in India, and necessitates robust literature review, for advocacy and action. Objective: To identify, synthesize and summarize current evidence to guide scaling up of management of diarrhea among under-five children in India, and identify existing knowledge gaps.

  14. Mechanisms of infectious diarrhea

    Infectious diarrhea is a global health issue that affects billions of individuals annually. The diarrheas can be classified as noninflammatory or inflammatory based on their pathogenesis and ...

  15. Update on Diarrhea

    The mainstay of management of infectious diarrheal illness in children remains supportive care with oral or intravenous rehydration. In the postvaccine era, norovirus has supplanted rotavirus as the leading cause of gastroenteritis presenting to medical facilities in the United States.After reading this article, the reader should be able to:Diarrhea is a worldwide problem that is frequently ...

  16. A Review on Prevention Interventions to Decrease Diarrheal ...

    Purpose of Review Provide an overview about childhood diarrhea burden and prevention interventions with demonstrated impact in reducing disease risk. Recent Findings Diarrhea incidence and mortality in children is declining around the world. A few pathogens cause most of the burden (rotavirus, norovirus, Shigella, enterotoxigenic E. coli, Campylobacter, and Cryptosporidium). Available ...

  17. Systematic review of diarrhea duration and severity in children and

    Systematic literature review. The systematic literature search yielded 5708 titles for children (Figure (Figure1), 1), of which we identified 41 and 27 studies for inclusion in the analysis of duration [8-48] and severity [8,9,16,19,21,22,25,26,36,39,43,45,49-63], respectively. All included studies reported data on children 0-59 months of age.

  18. Prevalence, patterns, and predictors of diarrhea: a spatial-temporal

    The time between birth and age 5 of a child's life represents a sensitive period for development [1, 2].The developmental construct of the physical health and well-being of a U-5 includes physical readiness for the school day, physical liberation, and gross and fine motor skills. Diarrhea is a gastrointestinal infection caused by pathogenic microorganisms including E. coli, Rotavirus ...

  19. Harmful practices in the management of childhood diarrhea in low- and

    Harmful practices in the management of childhood diarrhea are associated with negative health outcomes, and conflict with WHO treatment guidelines. These practices include restriction of fluids, breast milk and/or food intake during diarrhea episodes, and incorrect use of modern medicines. We conducted a systematic review of English-language literature published since 1990 to assess the ...

  20. Meta-analysis of the efficacy of probiotics to treat diarrhea

    Background: To collect the published trials of probiotics in the treatment of diarrhea and to strictly evaluate and systematically analyze the efficacy of probiotics use for the prevention and treatment of patients with diarrhea. Methods: We searched domestic and foreign literature published between January 2016 and July 2022 to find randomized control trials that used probiotics to treat ...

  21. PDF A Global Review of Diarrhoeal Disease Control

    The review process included computerized literature sea rches and contact with international agencies and with individual researchers in the regions. UNICEF also commissioned five expert groups t o prep are a comprehensive regional report, which was presented to a meeting of interested parties at UNICEF/New York in April 1993.

  22. Clinical characteristics and literature review of chronic active

    Clinical characteristics and literature review of chronic active Epstein-Barr virus-associated enteritis. Yajie Meng, Yajie Meng. ... The main clinical manifestations were fever (25/27), abdominal pain (14/27), diarrhea (16/27), hematochezia or bloody stools (13/27), and decreased hemoglobin and red blood cell counts in routine blood tests ...

  23. Explosive (severe) diarrhea: Causes, treatment, and complications

    Explosive diarrhea is a forceful form of loose or liquid stool. This severe type of diarrhea can result from infection, food intolerance, or certain medications, among other causes. In this ...

  24. The burden of diarrhea, etiologies, and risk factors in India from 1990

    Burden of diarrhea - number of deaths, mortality, and DALYs. Table 1 presents the number of diarrhea deaths and mortality rate (per 100,000 population) in 2019 in India for each age group and sex. The latest data in 2019 shows, the total number of deaths of all ages is 632,344 in 2019 (95% uncertainty interval; 358,561-1,056,036), and the mortality rate is 45 per 100,000 population (95% ...

  25. Home-based management practice of diarrhea in under 5 years old

    Diarrhea is one of the leading causes of morbidity and mortality in children under the age of 5 all over the world, particularly in underdeveloped countries where there is a lack of knowledge and practice in the management of diarrheal disease. 2 Every year, there are around 1.7 billion diarrheal cases among children under the age of 5 in the ...

  26. Clostridium spiroforme-associated enteric disease in domestic rabbits

    Clostridium spiroforme has been associated with spontaneous and antibiotic-associated enteric disease (C. spiroforme-associated enteric disease, CSAED) in rabbits, which is clinically characterized by anorexia, diarrhea, or sudden death.Diagnosis is usually based on gross and microscopic lesions, coupled with finding the characteristic coiled bacteria in intestinal smears.

  27. Diarrheal Diseases

    In contrast to mortality trends, morbidity due to diarrhea has not shown a parallel decline, and global estimates remain between two and three episodes of diarrhea per child under five per year. Kosek, Bern, and Guerrant (2003) estimated a global median incidence of diarrhea to be 3.2 episodes per child-year in the year 2000, similar to those found in previous reviews by Snyder and Merson ...