Abstract
SummaryBackgroundDiarrhoea is a leading cause of death and illness globally among children younger than 5 years. Mortality and short-term morbidity cause substantial burden of disease but probably underestimate the true effect of diarrhoea on population health. This underestimation is because diarrhoeal diseases can negatively affect early childhood growth, probably through enteric dysfunction and impaired uptake of macronutrients and micronutrients. We attempt to quantify the long-term sequelae associated with childhood growth impairment due to diarrhoea.MethodsWe used the Global Burden of Diseases, Injuries, and Risk Factors Study framework and leveraged existing estimates of diarrhoea incidence, childhood undernutrition, and infectious disease burden to estimate the effect of diarrhoeal diseases on physical growth, including weight and height, and subsequent disease among children younger than 5 years. The burden of diarrhoea was measured in disability-adjusted life-years (DALYs), a composite metric of mortality and morbidity. We hypothesised that diarrhoea is negatively associated with three common markers of growth: weight-for-age, weight-for-height, and height-for-age Z-scores. On the basis of these undernutrition exposures, we applied a counterfactual approach to quantify the relative risk of infectious disease (subsequent diarrhoea, lower respiratory infection, and measles) and protein energy malnutrition morbidity and mortality per day of diarrhoea and quantified the burden of diarrhoeal disease due to these outcomes caused by undernutrition.FindingsDiarrhoea episodes are significantly associated with childhood growth faltering. We found that each day of diarrhoea was associated with height-for-age Z-score (–0·0033 [95% CI −0·0024 to −0·0041]; p=4·43 × 10−14), weight-for-age Z-score (–0·0077 [–0·0058 to −0·0097]; p=3·19 × 10−15), and weight-for-height Z-score (–0·0096 [–0·0067 to −0·0125]; p=7·78 × 10−11). After addition of the DALYs due to the long-term sequelae as a consequence of undernutrition, the burden of diarrhoeal diseases increased by 39·0% (95% uncertainty interval [UI] 33·0–46·6) and was responsible for 55 778 000 DALYs (95% UI 49 125 400–62 396 200) among children younger than 5 years in 2016. Among the 15 652 300 DALYs (95% UI 12 951 300–18 806 100) associated with undernutrition due to diarrhoeal episodes, more than 84·7% are due to increased risk of infectious disease, whereas the remaining 15·3% of long-term DALYs are due to increased prevalence of protein energy malnutrition. The burden of diarrhoea has decreased substantially since 1990, but progress has been greater in long-term (78·7% reduction [95% UI 69·3–85·5]) than in acute (70·4% reduction [95% UI 61·7–76·5]) DALYs.InterpretationDiarrhoea represents an even larger burden of disease than was estimated in the Global Burden of Disease Study. In order to adequately address the burden of its long-term sequelae, a renewed emphasis on controlling the risk of diarrhoea incidence may be required. This renewed effort can help further prevent the potential lifelong cost on child health, growth, and overall potential.FundingBill & Melinda Gates Foundation.
Highlights
Measurement of prevalence, incidence, and mortality associated with diarrhoeal diseases is important for policy decisions, resource allocation, and targeted interventions, but it might not provide a complete understanding of the true disease burden
From a series of random-effects meta-analyses, we found that per day of diarrhoea, height-for-age decreased by 0·0033 SDs, weight-for-age decreased by 0·0077 SDs (0·0058–0·0097; p=3·19 × 10–15), and weight-for-height decreased by 0·0096 SDs (0·0067–0·0125; p=7·78 × 10–11; appendix)
Diarrhoeal diseases were responsible for about 40 125 700 Disability-adjusted life-years (DALYs) from diarrhoea incidence and deaths among children younger than 5 years in 2016, including about 446 000 deaths (390 900–504 600) and 1105 million episodes (962 million to 1275 million).[3,7,8]
Summary
Measurement of prevalence, incidence, and mortality associated with diarrhoeal diseases is important for policy decisions, resource allocation, and targeted interventions, but it might not provide a complete understanding of the true disease burden. Evidence is increasing that child hood diarrhoea, especially in the first 2 years of life, can negatively affect nutrient absorption, leading to poor physical growth.[1,2] Additional measures of long-term health loss due to diarrhoea, other than incidence and mortality, are needed. We identified 198 publications, including 17 that provided information about the association between diarrhoea and childhood growth. Many of these studies found an association between diarrhOea, measured as prevalence or cumulative exposure, and childhood growth indicators but varied in exposure and outcome definitions. We identified several publications that reviewed this association, but none attempted to systematically quantify the burden of diarrhoea on childhood growth
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