More than half a million children die from diarrhea each year. How do we prevent this?

Diarrheal diseases are one of the biggest killers of children worldwide

In 2017, almost 1.6 million people died from diarrheal diseases globally.

This is more than all deaths from all ‘intentional injuries’ combined in the same year: almost 800,000 died from suicide, 405,000 from homicide, 130,000 in conflict, and 26,500 from terrorism – in total 1,355,000.1

As the visualization shows, one-third of all who died from diarrheal diseases were children under five years old. For most of the past three decades under-5s have accounted for the majority of deaths from diarrheal diseases – back in 1990 it killed 1.7 million children.

Diarrheal disease was the cause of every tenth child’s death in 2017 – more than half a million of the 5.4 million children that died in 2017 died from diarrheal disease.

Diarrheal diseases are the third leading cause of child mortality globally, falling just behind pneumonia and preterm birth complications.

Where are children dying from diarrheal diseases?

The death rate from diarrheal diseases is highest in the world’s poorest countries: this chart shows the relationship between the death rate from diarrheal diseases and the country’s average income.

The death rate from diarrheal diseases in many of the poorest countries is higher than 100 annual deaths per 100,000 children. In those countries with the worst health – including Madagascar, Chad and the Central African Republic – the rate is higher than 300 per 100,000.

In high-income countries the death rate is very low. In many European countries, but also some rich Asian countries the rate is below 1 per 100,000 per year.

At lower levels of income risk factors for diarrheal diseases such as lack of access to clean water, rotavirus vaccine availability, undernutrition, stunting and others are the most prevalent.2

What causes diarrheal diseases in children?

Understanding the cause of disease is important so that we can set our priorities on the interventions and treatments that would save most lives, e.g. developing vaccines against the main agents for diarrhea and using antibiotic treatments only when they are appropriate.

Diarrheal diseases are caused primarily by viral and bacterial pathogens. The visualization shows the major pathogens responsible for diarrhea in children; the area of each box corresponds to the number of deaths from diarrhea in 2016 that can be attributed to each pathogen.

While bacterial pathogens (shown in red) are the major group of organisms responsible for diarrheal diseases, rotavirus is the single largest causative agent.3

Diarrhea cause treemap 2

Why are children still dying from diarrhea?

There are two main reasons why the number of children dying from diarrhea is still so large – the prevalence of diarrhea-associated risk factors and the lack of access to essential treatment.

The figure shows the number of deaths associated with the major risks factors for diarrheal diseases: unsafe drinking water, poor sanitation and malnutrition are responsible for the largest portion of deaths.

Since 1990 we have made a lot of progress in reducing these major risks; you can read more in our research entries on Hunger and Undernourishment, Extreme Poverty and Water Use and Sanitation. But continued progress is still needed.

In addition to reducing exposure to risks factors, increasing access to oral rehydration therapy (ORT), therapeutic zinc use and the coverage of rotavirus vaccines were all shown to be essential for reducing the burden of diarrheal diseases in children.4

How can we stop child deaths from diarrhea?

Diarrheal diseases are both ‘preventable and treatable’, as the WHO says, because we already know how to deal with many of the risk factors that may lead to diarrhea and, if diarrhea cannot be avoided, we know how to treat it.

The table below lists the range of interventions available for the treatment of diarrhea we have today.5

Some of these interventions, such as ORS, breastfeeding and improvements in sanitation broadly target all-causes of diarrhea, whereas, vaccination and antibiotic use are specifically directed against the causative agents of the disease.

Water, sanitation and hygiene (WASH) interventions are the best way to prevent diarrheal diseases. Hand washing with soap, better water quality and better sanitation have been shown to reduce the risk of diarrheal infections by  47%, 17% and 36%, respectively.6

Educating mothers about the importance of breastfeeding is also important. Breastfeeding allows for the transfer of maternal immunity to the child – in developing countries infants that are not breastfed are six times more likely to die from infectious diseases, such as those causing to diarrhea, in the first 2 months of their lives.7

Another way to prevent diarrheal diseases is vaccination. Until relatively recently, there were few vaccines available to prevent diarrheal diseases. Cholera vaccine has been licensed since 1991 but it is primarily given to travelers and used as an outbreak control measure. This is because targeted immunization combined with other sanitary measures is more cost-effective than immunizing every individual with a vaccine that only provides a few years of protection.8

In 2006, however, new vaccines against rotavirus – the leading cause of childhood diarrhea as the treemap above shows – have been introduced. The most recent studies show that, while the effectiveness of the new rotavirus vaccines vary across different countries, it works well in protecting children against rotavirus disease.9

We will explore the success, potential and limitations of rotavirus vaccines in an upcoming post.

When preventative measures fail, several options for the treatment of diarrheal diseases are available, including nutritional interventions and antibiotic use when necessary. But the single best treatment for diarrheal diseases is a surprisingly simple mixture of water, salt and sugar: otherwise known as the oral rehydration solution.10

The estimates of ORS effectiveness vary by source, with some suggesting that the current use of ORS helps to prevent 69% of diarrheal deaths and, if its coverage would be increased close to 100%, 93% of diarrheal deaths could be prevented.11

We will look in more detail at the specific prevention and treatment measures against diarrheal diseases in upcoming posts. This should help to make clear what is possible and effective in preventing and treating one of the leading causes of death in children.

Potential of interventions to prevent the burden of diarrheal diseases in childhood12
InterventionEstimate of the effect size
Handwashing with soap48% risk reduction
Improved water quality17% risk reduction
Excreta disposal (improved sanitation)36% risk reduction
Breastfeeding education43% increase in exclusive breastfeeding rates at day 1, 30% increase until 1 month, and 90% increase from 1-6 months
Preventive zinc supplementation13% reduction in diarrhea incidence, but no effect on mortality
Therapeutic zinc supplementation46% reduction in all-cause mortality and 23% reduction in hospitalization due to diarrhea
Rotavirus vaccines74% effectiveness against very severe rotavirus infection; 61% against severe; 47% reduction in hospitalization
Cholera vaccines52% effective against cholera infection
Oral rehydration solution (ORS)69% reduction in diarrhea-specific mortality
Dietary management for diarrhea 47% reduction in diarrhea treatment failure and 47% reduction in treatment failure
Antibiotics for cholera63% reduction in clinical failure rates
Antibiotics for Shigella82% reduction in clinical failure rates
Antibiotics for cryptosporidiosis 52% reduction in clinical failure rates
Community-based interventions (home visits and healthcare promotion)160% increase in ORS use and 80% increase in zinc use. 9% increase in seeking care for diarrhea and 75% reduction in inappropriate antibiotic use