Stop the Cycle

Challenge

Across all ages, diarrheal disease causes more illnesses than any other ailment and is second only to pneumonia as the largest killer of children under five years. Children who survive an episode of diarrhea, but experience recurring infections, are more likely to suffer from lifelong cognitive and physical impairments.

The state of the field is changing

Diarrheal disease is preventable and treatable, and more children than ever have these tools within reach. Although this has led to a decline in deaths in recent years, children are still getting sick, facing the long-term consequences of malnutrition and repeated infections.

Importantly, subnational data show that the children at highest risk of diarrhea death or long-term health impacts are in the poorest regions. Diarrhea burden is a manifestation of broader inequity; these children bear the brunt of COVID-19’s cascading impact, including declining immunization rates and strains on already fragile health systems. Gender equity, antibiotic resistance, climate change, conflict, and rapid urbanization exacerbate the risks.

The World Health Organization (WHO) defines diarrhea as the passage of three or more loose or liquid stools per day. Also known as gastroenteritis, diarrheal disease is caused by germs (both viral and bacterial) and parasites that are spread from the waste of an infected person to the mouth of another person through contaminated water, food, objects, or hands. During a diarrhea episode, fluids are depleted. Diarrhea becomes deadly when it results in dehydration that goes untreated. Infants and young children are especially vulnerable to rapid dehydration.

The top six pathogens responsible for diarrhea are:

Shigella

Rotavirus

Adenovirus

Enterotoxigenic E. coli

Cryptosporidium

Campylobacter

It’s not a hopelessly long list of infections that we can’t do anything about.

- Dr. Eric Houpt, Professor of Infectious Diseases and International Health, University of Virginia
Humanosphere

Who is at risk?

Diarrhea is a threat everywhere, but its frequency and impact are more severe in low-resource settings. Just 15 countries carry 70% of the global diarrheal burden, and progress on tackling this resilient threat is inconsistent, according to the International Vaccine Access Center’s 2023 Progress Report. Whether a child survives a diarrhea infection often depends on where he or she lives and receives treatment. In poorer countries, where access to hospitals or other forms of basic medical care—including intravenous (IV) fluids—may be limited, diarrheal disease can cause death or lasting impairments.

Diarrhea is deadly and dangerous

Deaths from diarrhea disproportionately impact children living in poverty due to:

  • Inadequate water supply/unsafe drinking water
  • Lack of access to sanitation (the safe disposal of human waste)
  • Limited access to soap and water and knowledge of good hygiene practices
  • Limited access to vaccines
  • Limited access to health care
  • Limited knowledge about diarrhea prevention and treatment

Globally, unsafe water and sanitation are the leading risk factors for diarrhea. Infants who are not exclusively breastfed or are malnourished, and immunocompromised young children and adults are also at great risk.

Despite substantial reductions in deaths among children under five years—from more than 1 million to less than 450,000 each year in the last two decades—diarrhea remains one of the deadliest threats young children face. Specifically, it is responsible for about nine percent of all worldwide deaths in young children.

The latest available estimates on diarrheal disease-related deaths are summarized below. Findings across sources are relatively consistent.

Global Burden of Disease (GBD) Study/Institute for Health Metrics and Evaluation (IHME)

Latest estimates: 2019, published 2020

IGME UN Inter-agency Group for Child Mortality Estimation

Latest estimates: 2021, published 2023

Total number <5 deaths

5.04 million

Total number <5 deaths

4.9 million

Annual number <5 diarrheal deaths

500,664

Annual number <5 diarrheal deaths

443,833

Percent of all <5 deaths due to diarrhea

9.9%

Percent of all <5 deaths due to diarrhea

9%

Change:

From 2010 to 2019, diarrhea deaths among children under 5 years decreased by 60%.

Change:

From 2000 to 2021, diarrhea deaths among children under 5 years decreased by 63%.

NIGERIA

135,857

Deaths

INDIA

39,863

Deaths

PAKISTAN

27,466

Deaths

DEMOCRATIC REPUBLIC OF CONGO

25,791

Deaths

ETHIOPIA

15,936

Deaths

NIGER

15,273

Deaths

CHAD

11,453

Deaths

TANZANIA

10,264

Deaths

ANGOLA

10,251

Deaths

SOMALIA

10,228

Deaths

The United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) data demonstrates that there can be significant inequities between countries. For a deeper look at progress, challenges, and opportunities in each high-burden country, check out these Child Health Spotlights from Save the Children and UNICEF.

 

We can make public health gains when we invest in the right solutions and strategies—and then motivate policymakers to accelerate progress and ‘finish the job.’ Often, the biggest obstacle is people thinking that aid doesn’t pay off. With diarrhea, it has and still can.

- Eileen Quinn, Director, Advocacy and Communications, Center for Vaccine Innovation and Access at PATH

Diarrhea deaths are preventable

Diarrhea can be prevented by:

Diarrhea can be treated by:

Diarrhea can be prevented by:

Vaccines

WASH

Breastfeeding & Nutrition

Diarrhea can be treated by:

ORS & Zinc

Research

Simple and proven solutions can prevent and treat diarrhea. Integrating them together achieves the greatest impact.

Deaths are not the only problem—young children are still getting sick

Diarrhea infections are not declining as fast as the rate of deaths. While diarrhea deaths declined significantly among young children between between 2019 and 2021, there were only three percent fewer deaths caused by diarrhea, according to research from the United Nations. In 2019 alone, there were over 15 million episodes of diarrhea in young children worldwide.

This means children are surviving, but not necessarily thriving—or not necessarily living their healthiest life. The magnitude is huge, but the problem still lacks the recognition and prioritization it urgently requires.

Diarrhea has devastating, lasting implications for children and families

Many studies demonstrate that repeated diarrhea infections, especially within the first two years of life, can cause long-term disability, diminishing a child’s quality of life and potentially causing premature death.

Recurring enteric infections, such as those caused by diarrheal disease, may lead to intestinal inflammation and damage in the gut. Compromised gut health inhibits nutrient absorption in the body. This can lead to malnutrition and lasting health consequences, such as stunted physical growth, impaired cognitive development, and/or increased susceptibility to infections, including diarrheal disease and pneumonia. The better we understand these implications, the better we can make meaningful policy decisions to break the cycle of poor health by using strategies and solutions that work together.

We are saving more lives from diarrhea, but what is the future for kids who grow up sick much of their lives? Once a child developmentally misses an opportunity to grow, you can never fix that.

- Dr. Roma Chilengi, Chief Scientific Officer, Centre for Infectious Disease Research in Zambia (CIDRZ)
DefeatDD Blog

No child’s life should be limited by diarrhea

Diarrhea imposes a devastating burden on communities—not just in terms of deaths and illnesses, but also in terms of finances.

When a young child has multiple episodes of diarrhea, he/she is left vulnerable to other infections, malnutrition, and stunting, which can take a lifelong toll on that child’s ability to grow, thrive, and contribute to society.

  • When a child gets sick, he/she may miss school and his/her parents must pay for care, which could amount to a significant portion of that family’s income.
  • They may also need to stay home to care for their child or take him/her to the clinic or hospital, losing wages from missed time at work.
  • Especially in lower-income countries, the cost of diarrhea can push entire families into poverty, known as “medical impoverishment.”
  • Often, when one child gets sick, so do other family members. The impact is bigger than one child.
  • Stunting, the end result of long-term developmental deficits that repeated diarrhea can cause, is associated with a 25% reduction in average adult earning potential.

Many families are forced to make the impossible choice

When a children falls ill with diarrheal disease, families often have to chose between treatment and family finances. Treatment costs can cause significant financial strain on households and health care systems alike. A PATH analysis found that, across 137 low- and middle-income countries, modelled costs of childhood diarrhea averaged $52.16 per outpatient episode and $216.36 per inpatient episode, with a significant share of costs due to lost wages and indirect treatment costs like travel and lodging. For many families, including a quarter of those in a Malawi study, these costs are greater than or equal to the entire family’s monthly income. This type of expense can too often push families into poverty.

bar chart showing costs of diarrhea

Take action

Policy decisions are made based on local needs and burden. Find out about diarrhea in your region/country with these resources.

Where to learn more about diarrheal disease

Yes, we've made progress, but there's more to be done.

It’ll take focus and prioritization from governments and donors, integrated efforts such as the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD), and continued pressure and calls for accountability by advocates.

Continue to Solutions

Further reading: