Morbidity and mortality due to shigella and enterotoxigenic Escherichia coli diarrhoea: the Global Burden of Disease Study 1990-2016

Abstract

Background: Shigella and enterotoxigenic Escherichia coli (ETEC) are bacterial pathogens that are frequently associated with diarrhoeal disease, and are a significant cause of mortality and morbidity worldwide. The Global Burden of Diseases, Injuries, and Risk Factors study 2016 (GBD 2016) is a systematic, scientific effort to quantify the morbidity and mortality due to over 300 causes of death and disability. We aimed to analyse the global burden of shigella and ETEC diarrhoea according to age, sex, geography, and year from 1990 to 2016.

Methods: We modelled shigella and ETEC-related mortality using a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We used a compartmental meta-regression tool to model the incidence of shigella and ETEC, which enforces an association between incidence, prevalence, and remission on the basis of scientific literature, population representative surveys, and health-care data. We calculated 95% uncertainty intervals (UIs) for the point estimates.

Findings: Shigella was the second leading cause of diarrhoeal mortality in 2016 among all ages, accounting for 212 438 deaths (95% UI 136 979-326 913) and about 13·2% (9·2-17·4) of all diarrhoea deaths. Shigella was responsible for 63 713 deaths (41 191-93 611) among children younger than 5 years and was frequently associated with diarrhoea across all adult age groups, increasing in elderly people, with broad geographical distribution. ETEC was the eighth leading cause of diarrhoea mortality in 2016 among all age groups, accounting for 51 186 deaths (26 757-83 064) and about 3·2% (1·8-4·7) of diarrhoea deaths. ETEC was responsible for about 4·2% (2·2-6·8) of diarrhoea deaths in children younger than 5 years.

Interpretation: The health burden of bacterial diarrhoeal pathogens is difficult to estimate. Despite existing prevention and treatment options, they remain a major cause of morbidity and mortality globally. Additional emphasis by public health officials is needed on a reduction in disease due to shigella and ETEC to reduce disease burden.

Funding: Bill & Melinda Gates Foundation.

Figure 1

The age distribution of the population attributable fraction of diarrhoea mortality at the global level in 2016 for shigella and ETEC The population attributable fraction represents the proportion of diarrhoea deaths that are due to each pathogen. Ribbons are 95% uncertainty intervals around the mean estimates. ETEC=enterotoxigenic Escherichia coli. EN=early neonatal. LN=late neonatal. PN=postnatal.

Figure 2

The age distribution of shigella and ETEC deaths globally in 2016 Error bars are 95% uncertainty interval. ETEC=enterotoxigenic Escherichia coli. EN=early neonatal. LN=late neonatal. PN=postnatal.

Figure 3

Shigella (A) and enterotoxigenic Escherichia coli (B) diarrhoea mortality rate per 100 000 people in 2016 for all ages ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. Isl=Islands. FSM=Federated States of Micronesia. TLS=Timor-Leste.

Figure 4

Shigella (A) and ETEC (B) population attributable fraction by sociodemographic index, 2016 Sociodemographic index is a measure of the relative development of a country, with high values indicating more development. Ribbons are 95% uncertainty intervals. Point colours are GBD super-regions. ETEC=enterotoxigenic Escherichia coli.

Figure 5

Association between standard error of PAF and GBD super region Data are the standard error of the mean PAF. ETEC=enterotoxigenic Escherichia coli. PAF=population attributable fraction.