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Cited by 200Child Nutrition and Water AccessViral gastroenteritis research and epidemiologyGlobal Maternal and Child Health

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Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years

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Troeger, Christopher, Colombara, Danny V, Rao, Puja C, Khalil, Ibrahim A, Brown, Alexandria, Brewer, Thomas G, Guerrant, Richard L, Houpt, Eric R, Kotloff, Karen L, Misra, Kavita, Petri, William A, Platts-Mills, James, Riddle, Mark S, Swartz, Scott J, Forouzanfar, Mohammad H, Reiner, Robert C, Hay, Simon I, Mokdad, Ali H·2018·The Lancet Global Health
DOI 10.1016/s2214-109x(18)30045-7PMC PMC5861379
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Abstract

BACKGROUND: Diarrhoea 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. METHODS: We 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. FINDINGS: ). 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. INTERPRETATION: Diarrhoea 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. FUNDING: Bill & Melinda Gates Foundation.

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Figure 1 Diarrhoea DALYs The total diarrhoea DALYs represents the sum of acute and long-term sequelae DALYs per 1000 children younger than 5 years in 2016. (A) The sum of the acute DALYs (diarrhoea incidence and mortality) and long-term sequelae diarrhoea DALYs due to growth impairment per 1000 children younger than 5 years in 2016. (B) The relative percentage increase in the total number of DALYs due to diarrhoeal diseases in 2016 among children younger than 5 years after inclusion of the long-term sequelae diarrhoea DALYs compared with the acute diarrhoea DALYs only. ATG=Antigua and Barbuda. BRB=Barbados. COM=Comoros. DALYs=disability-adjusted life-years. DMA=Dominica. FJI=Fiji. FSM=Federated States of Micronesia. GRD=Grenada. KIR=Kiribati. LCA=Saint Lucia. MDV=Maldives. MHL=Marshall Islands. MLT=Malta. MUS=Mauritius. SGP=Singapore. SLB=Solomon Islands. SYC=Seychelles. TLS=Timor-Leste. TON=Tonga. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines. VUT=Vanuatu. WSM=Samoa.
Figure 1 Diarrhoea DALYs The total diarrhoea DALYs represents the sum of acute and long-term sequelae DALYs per 1000 children younger than 5 years in 2016. (A) The sum of the acute DALYs (diarrhoea incidence and mortality) and long-term sequelae diarrhoea DALYs due to growth impairment per 1000 children younger than 5 years in 2016. (B) The relative percentage increase in the total number of DALYs due to diarrhoeal diseases in 2016 among children younger than 5 years after inclusion of the long-term sequelae diarrhoea DALYs compared with the acute diarrhoea DALYs only. ATG=Antigua and Barbuda. BRB=Barbados. COM=Comoros. DALYs=disability-adjusted life-years. DMA=Dominica. FJI=Fiji. FSM=Federated States of Micronesia. GRD=Grenada. KIR=Kiribati. LCA=Saint Lucia. MDV=Maldives. MHL=Marshall Islands. MLT=Malta. MUS=Mauritius. SGP=Singapore. SLB=Solomon Islands. SYC=Seychelles. TLS=Timor-Leste. TON=Tonga. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines. VUT=Vanuatu. WSM=Samoa.CC BY · PubMed Central
Figure 2 Number of short-term (acute) and long-term sequelae DALYs per 1000 children under 5 years old by Global Burden of Disease region in 2016 DALY=disability-adjusted life-year.
Figure 2 Number of short-term (acute) and long-term sequelae DALYs per 1000 children under 5 years old by Global Burden of Disease region in 2016 DALY=disability-adjusted life-year.CC BY · PubMed Central
Figure 3 Absolute number of short-term (acute) and long-term sequelae DALYs by Global Burden of Disease super-region and age group in 2016 DALY=disability-adjusted life-year.
Figure 3 Absolute number of short-term (acute) and long-term sequelae DALYs by Global Burden of Disease super-region and age group in 2016 DALY=disability-adjusted life-year.CC BY · PubMed Central
Figure 4 Total diarrhoea DALYs per 1000 globally and by Global Burden of Disease super-region by year among children younger than 5 years DALY=disability-adjusted life-year.
Figure 4 Total diarrhoea DALYs per 1000 globally and by Global Burden of Disease super-region by year among children younger than 5 years DALY=disability-adjusted life-year.CC BY · PubMed Central

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Authors
Troeger, C., Colombara, D. V., Rao, P. C., Khalil, I. A., Brown, A., Brewer, T. G., Guerrant, R. L., Houpt, E. R., Kotloff, K. L., Misra, K., Petri, W. A., Platts-Mills, J., Riddle, M. S., Swartz, S. J., Forouzanfar, M. H., Reiner, R. C., Hay, S. I., & Mokdad, A. H.
Affiliations
  • University of Washington (US)
  • University of Virginia (US)
  • University of Maryland, Baltimore (US)
  • New York City Department of Health and Mental Hygiene (US)
  • Uniformed Services University of the Health Sciences (US)
Corresponding author
Mokdad, Ali H
ORCID
Venue
The Lancet Global Health
Publisher
Elsevier BV
Published
2018-03
Volume
6
Issue
3
Pages
e255-e269
ISSN
2214-109X (ISSN-L)
DOI
10.1016/s2214-109x(18)30045-7
PMC
PMC5861379
OpenAlex
W2785669008
Cited by
200
References
39
Citations by year
2026: 22 · 2025: 25 · 2024: 28 · 2023: 24 · 2022: 19 · 2021: 19 · 2020: 22 · 2019: 29 · 2018: 12
FWCI
16.96
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Global Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
National Institute of Allergy and Infectious Diseases (R01AI043596)
Topics
  • Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
  • Health Sciences › Medicine › Infectious Diseases › Viral gastroenteritis research and epidemiology
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
Keywords
child undernutrition, disability-adjusted life years, protein-energy malnutrition, lower respiratory tract infection, measles, weight-for-age, height-for-age, weight-for-height, children under five, global burden of disease, micronutrient uptake, infectious disease risk
MeSH terms
Child, Preschool, Diarrhea, Female, Growth Disorders, Disabled Persons, Persons with Disabilities, Humans, Infant, Male, Time Factors, Global Health, Cost of Illness, Quality-Adjusted Life Years, Malnutrition

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