Aetiology and incidence of diarrhoea requiring hospitalisation in children under 5 years of age in 28 low-income and middle-income countries: findings from the Global Pediatric Diarrhea Surveillance network

Abstract

Introduction: Diarrhoea remains a leading cause of child morbidity and mortality. Systematically collected and analysed data on the aetiology of hospitalised diarrhoea in low-income and middle-income countries are needed to prioritise interventions.

Methods: We established the Global Pediatric Diarrhea Surveillance network, in which children under 5 years hospitalised with diarrhoea were enrolled at 33 sentinel surveillance hospitals in 28 low-income and middle-income countries. Randomly selected stool specimens were tested by quantitative PCR for 16 causes of diarrhoea. We estimated pathogen-specific attributable burdens of diarrhoeal hospitalisations and deaths. We incorporated country-level incidence to estimate the number of pathogen-specific deaths on a global scale.

Results: During 2017-2018, 29 502 diarrhoea hospitalisations were enrolled, of which 5465 were randomly selected and tested. Rotavirus was the leading cause of diarrhoea requiring hospitalisation (attributable fraction (AF) 33.3%; 95% CI 27.7 to 40.3), followed by Shigella (9.7%; 95% CI 7.7 to 11.6), norovirus (6.5%; 95% CI 5.4 to 7.6) and adenovirus 40/41 (5.5%; 95% CI 4.4 to 6.7). Rotavirus was the leading cause of hospitalised diarrhoea in all regions except the Americas, where the leading aetiologies were Shigella (19.2%; 95% CI 11.4 to 28.1) and norovirus (22.2%; 95% CI 17.5 to 27.9) in Central and South America, respectively. The proportion of hospitalisations attributable to rotavirus was approximately 50% lower in sites that had introduced rotavirus vaccine (AF 20.8%; 95% CI 18.0 to 24.1) compared with sites that had not (42.1%; 95% CI 33.2 to 53.4). Globally, we estimated 208 009 annual rotavirus-attributable deaths (95% CI 169 561 to 259 216), 62 853 Shigella-attributable deaths (95% CI 48 656 to 78 805), 36 922 adenovirus 40/41-attributable deaths (95% CI 28 469 to 46 672) and 35 914 norovirus-attributable deaths (95% CI 27 258 to 46 516).

Conclusions: Despite the substantial impact of rotavirus vaccine introduction, rotavirus remained the leading cause of paediatric diarrhoea hospitalisations. Improving the efficacy and coverage of rotavirus vaccination and prioritising interventions against Shigella, norovirus and adenovirus could further reduce diarrhoea morbidity and mortality.

Keywords: PCR; child health; epidemiology; infections, diseases, disorders, injuries; public health.

Figure 1

Pathogen-specific attributable fractions of hospitalised diarrhoea in children less than 5 years of age in 2017–2018 for the 33 surveillance sites from 28 countries in Global Pediatric Diarrhea Surveillance. The map indicates the country locations as well as their geographic groupings and the bar plots are coloured according to those groupings. Attributable fractions are expressed as a percent. *Rotavirus vaccine not introduced by 2017. ETEC, enterotoxigenic E. coli.

Figure 2

Pathogen-specific attributable fractions of hospitalised diarrhoea in children less than 5 years of age in 2017–2018 in Global Pediatric Diarrhea Surveillance both overall and by geographic region. Within each grouping and pathogen to attributable fractions were weighted by the site-level attributable incidence of hospitalised diarrhoea. Attributable fractions are expressed as a per cent. ETEC, enterotoxigenic E. coli.

Figure 3

Pathogen-specific attributable fractions of hospitalised diarrhoea in children less than 5 years of age in 2017–2018 in Global Pediatric Diarrhea Surveillance both overall and by geographic region to by rotavirus vaccination introduction status as of 2017. For each grouping, attributable fractions were weighted by the site-level attributable incidence of hospitalised diarrhoea. Attributable fractions are expressed as a percent. ETEC, enterotoxigenic E. coli.