Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 May;25(5):519-536.
doi: 10.1016/S1473-3099(24)00691-1. Epub 2024 Dec 18.

Global, regional, and national age-sex-specific burden of diarrhoeal diseases, their risk factors, and aetiologies, 1990-2021, for 204 countries and territories: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 Diarrhoeal Diseases Collaborators
Collaborators

Global, regional, and national age-sex-specific burden of diarrhoeal diseases, their risk factors, and aetiologies, 1990-2021, for 204 countries and territories: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 Diarrhoeal Diseases Collaborators. Lancet Infect Dis. 2025 May.

Abstract

Background: Diarrhoeal diseases claim more than 1 million lives annually and are a leading cause of death in children younger than 5 years. Comprehensive global estimates of the diarrhoeal disease burden for specific age groups of children younger than 5 years are scarce, and the burden in children older than 5 years and in adults is also understudied. We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 to assess the burden of, and trends in, diarrhoeal diseases overall and attributable to 13 pathogens, as well as the contributions of associated risk factors, in children and adults in 204 countries and territories from 1990 to 2021.

Methods: We used the Cause of Death Ensemble modelling strategy to analyse vital registration data, verbal autopsy data, mortality surveillance data, and minimally invasive tissue sampling data. We used DisMod-MR (version 2.1), a Bayesian meta-regression tool, to analyse incidence and prevalence data identified via systematic reviews, population-based surveys, and claims and inpatient data. We calculated diarrhoeal disability-adjusted life-years (DALYs) as the sum of years of life lost (YLLs) and years lived with disability (YLDs) for each location, year, and age-sex group. For aetiology estimation, we used a counterfactual approach to quantify population-attributable fractions (PAFs). Additionally, we estimated the diarrhoeal disease burden attributable to the independent effects of risk factors using the comparative risk assessment framework.

Findings: In 2021, diarrhoeal diseases caused an estimated 1·17 million (95% uncertainty interval 0·793-1·62) deaths globally, representing a 60·3% (50·6-69·0) decrease since 1990 (2·93 million [2·31-3·73] deaths). The most pronounced decline was in children younger than 5 years, with a 79·2% (72·4-84·6) decrease in diarrhoeal deaths. Global YLLs also decreased substantially, from 186 million (147-221) in 1990 to 51·4 million (39·9-65·9) in 2021. In 2021, an estimated 59·0 million (47·2-73·2) DALYs were attributable to diarrhoeal diseases globally, with 30·9 million (23·1-42·0) of these affecting children younger than 5 years. Leading risk factors for diarrhoeal DALYs included low birthweight and short gestation in the neonatal age groups, child growth failure in children aged between 1-5 months and 2-4 years, and unsafe water and poor sanitation in older children and adults. We estimated that the removal of all evaluated diarrhoeal risk factors would reduce global DALYs from 59·0 million (47·2-73·2) to 4·99 million (1·99-10·0) among all ages combined. Globally in 2021, rotavirus was the predominant cause of diarrhoeal deaths across all ages, with a PAF of 15·2% (11·4-20·1), followed by norovirus at 10·6% (2·3-17·0) and Cryptosporidium spp at 10·2% (7·03-14·3). In children younger than 5 years, the fatal PAF of rotavirus was 35·2% (28·7-43·0), followed by Shigella spp at 24·0% (15·2-37·9) and adenovirus at 23·8% (14·8-36·3). Other pathogens with a fatal PAF greater than 10% in children younger than 5 years included Cryptosporidium spp, typical enteropathogenicEscherichia coli, and enterotoxigenic E coli producing heat-stable toxin.

Interpretation: The substantial decline in the global burden of diarrhoeal diseases since 1990, particularly in children younger than 5 years, supports the effectiveness of health interventions such as oral rehydration therapy, enhanced water, sanitation, and hygiene (WASH) infrastructure, and the introduction and scale-up of rotavirus vaccination. Targeted interventions and preventive measures against key risk factors and pathogens could further reduce this burden. Continued investment in the development and distribution of vaccines for leading pathogens remains crucial.

Funding: Bill & Melinda Gates Foundation.

PubMed Disclaimer

Conflict of interest statement

Declaration of interests S Afzal reports support for the present manuscript from the provision of study material from HEC digital library, Pakistan; Payment or honoraria for educational events and webinars with King Edward Medical University and collaborative partners including Johns Hopkins University, University of California, and the University of Massachusetts; support for attending meetings and/or travel from King Edward Medical University; participation on a data safety monitoring board or advisory board with the National Bioethics Committee (Pakistan), King Edward Medical University Institutional Ethical Review Board, Ethical Review Board Fatima Jinnah Medical University, and Sir Ganga Ram Hospital; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid with Pakistan Association of Medical Editors, Fellow of Faculty of Public Health Royal Colleges UK (FFPH), Society of Prevention, Advocacy and Research (King Edward Medical University SPARK), and as a member of Pakistan Society of Infectious Diseases; other financial or non-financial interests serving as Dean of Public Health and Preventative Medicine of King Edward Medical University, as Chief Editor of Annals of King Edward Medical University, Directory Quality Enhancement Cell King Edward Medical University, member of Research and Publications Higher Education Commission (Pakistan), and member of the Pakistan Medical and Dental Council for Research and Publications Committee; outside the submitted work. T Bärnighausen reports grants or contracts paid to their institution from the National Institutes of Health, Alexander von Humboldt Foundation, German National Research Foundation (DFG), European Union, German Ministry of Education and Research, German Ministry of the Environment, Wellcome, and kfW; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from PLOS as the Editor-in-Chief; serving on two scientific advisory boards for NIH-funded research projects in Africa on climate change and health; stock or stock options in CHEERS; outside the submitted work. A Beloukas reports grants or contracts from Gilead (research grant and sponsorship to the University of West Attica) and GSK/ViiV (research sponsorship to the University of West Attica); payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Gilead, GSK/ViiV paid to the University of West Attica; support for attending meetings and/or travel from Gilead, GSK/ViiV paid to the University of Attica; and receipt of equipment, materials, drugs, medical writing, gifts or other services from Cepheid; outside the submitted work. M Ilic reports support for the present manuscript from the Ministry of Science, Technological Development and Innovation of the Republic of Serbia (no. 451-03-47/2023-01/20011). I Ilic reports support for the present manuscript from the Ministry of Science, Technological Development and Innovation of the Republic of Serbia (no. 175042, 2011-2023). N E Ismail reports leadership or fiduciary roles in other board, society, committee or advocacy group, unpaid as the Bursar and Council Member of Malaysian Academy of Pharmacy, and as Committee Member of Education Chapter of the Malaysian Pharmacists Society; outside the submitted work. J Jozwiak reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novartis, Adamed, and Amgen; outside the submitted work. K Krishan reports other non-financial support from the UGC Centre of Advanced Study, CAS II, awarded to the Department of Anthropology at Punjab University in Chandigarh (India); outside the submitted work. M-C Li reports support for the present manuscript from the National Science and Technology Council, Taiwan (NSTC 113-2314-B-003-002); leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid as the Technical Editor of the Journal of the American Heart Association; outside the submitted work. L Monasta reports support for the present manuscript from the Italian Ministry of Health (Ricerca Corrente 34/2017), payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. J F Mosser reports support for the present manuscript from the Bill & Melinda Gates Foundation; grant funding from Gavi; support for attending meetings and/or travel from the Bill & Melinda Gates Foundation; outside the submitted work. I N Okeke reports grants or contracts from the Bill & Melinda Gates Foundation, Wellcome Trust Sanger Institute, University of Ibadan, Oxford University, Danish Technical University, and receipt of the International Vaccine Institute Award as the Nigeria Country PI until 2021; royalties for Genetics: Genes, Genomes and Evolution (Oxford University Press), royalties for Divining Without Seeds: The case for strengthening laboratory Medicine in Africa (Cornell University Press), royalties for Antimicrobial Resistance in Developing Countries (Springer); consulting fees from Wellcome Trust, UK Proposal Review Panel; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from the Microbiology Society; support for attending meetings and/or travel from the Bill & Melinda Gates Foundation, European Society for Clinical Microbiology and Infectious Disease, and the American Society for Microbiology; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid with the Thomas Bassir Biomedical Foundation Nigeria, the International Centre for Antimicrobial Resistance Solutions (ICARS) Technical Advisory Forum 2021–2023, and additional pro-bono roles; other financial or non-financial interests as Editor in Chief (2017–2021) of the African Journal of Laboratory Medicine, Senior Editor (2022–) of Microbial Genomics, Scientific Advisor (2020–2021) of The Lancet Infectious Diseases, Surveillance Lead (2017–) of AMR Technical Work Group, Nigeria Center for Disease Control, as Commissioner (2020–2022) on The Lancet Commission for Nigeria, and payment for media (Podcast) event from The Wellcome Trust (2024); outside the submitted work. A P Okekunle reports support for the present manuscript from the National Research Foundation of Korea funded by the Ministry of Science and ICT (2020H1D3A1A04081265); support for attending meetings and/or travel from the National Research Foundation of Korea funded by the Ministry of Science and ICT (2020H1D3A1A04081265), outside the submitted work. L Ronfani reports support for the present manuscript from Italian Ministry of Health (Ricerca Corrente 34/2017) payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. Y L Samodra reports leadership or fiduciary roles in other board, society, committee or advocacy groups, paid or unpaid from Benang Merah Research Center (Indonesia) as Co-founder; outside the submitted work. J Sanabria reports support for attending meetings and/or travel from continuous medical education grant from the University School of Medicine; several patents granted and pending but no royalties; and Participation on a data safety monitoring board or advisory board for quality assessment and assurance for the department; outside the submitted work. V Sharma reports other financial or non-financial support from DFSS (MHA)'s research project (DFSS28(1)2019/EMR/6) at Institute of Forensic Science & Criminology, Panjab University (Chandigarh, India); outside the submitted work. J A Singh reports consulting fees from ROMTech, Atheneum, Clearview healthcare partners, American College of Rheumatology, Yale, Hulio, Horizon Pharmaceuticals, DINORA, ANI/Exeltis, USA Inc., Frictionless Solutions, Schipher, Crealta/Horizon, Medisys, Fidia, PK Med, Two labs Inc., Adept Field Solutions, Clinical Care options, Putnam associates, Focus forward, Navigant consulting, Spherix, MedIQ, Jupiter Life Science, UBM LLC, Trio Health, Medscape, WebMD, and Practice Point communications; and the National Institutes of Health; Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events as a member of the Speaker's Bureau of Simply Speaking; support for attending meetings and/or travel as a past steering committee member of OMERACT; participation on a data safety monitoring board or advisory board with FDA Arthritis Advisory Committee; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid as the Past steering committee member of the OMERACT, an international organization that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies, the Chair of the Veterans Affairs Rheumatology Field Advisory Committee, and the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis; stock or stock options in Atai life sciences, Kintara therapeutics, Intelligent Biosolutions, Acumen pharmaceutical, TPT Global Tech, Vaxart pharmaceuticals, Atyu biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals Holding Corp., Aebona Pharmaceuticals, and Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking and Moderna pharmaceuticals; outside the submitted work. J H V Ticoalu reports leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid as the Co-founder of Benang Merah Research Center (Indonesia); outside the submitted work. S J Tromans reports grants or contracts from the 2023 Adult Psychiatric Morbidity Survey team, collecting epidemiological data on community-based adults living in England, a contracted study from NHS Digital via the Department of Health and Social Care (payments made to the University of Leicester); outside the submitted work.

Figures

Figure 1
Figure 1
Diarrhoeal mortality rates per 100 000 and counts by broad age categories (A) and under-5 age groups (B), from 1990 to 2021 Shaded areas represent 95% uncertainty intervals. Early neonatal represents newborns aged 0–6 days. Late neonatal represents newborns aged 7–27 days.
Figure 2
Figure 2
Years of life lost due to diarrhoeal diseases by broad age categories (A) and under-5 age groups (B), from 1990 to 2021 Years of life lost are shown in millions with each colour representing one age group. Early neonatal represents newborns aged 0–6 days. Late neonatal represents newborns aged 7–27 days.
Figure 3
Figure 3
Age-standardised diarrhoeal mortality rates per 100 000 population in males (A) and females (B) in 2021 Grey shading indicates the location has no data.
Figure 4
Figure 4
Diarrhoeal DALYs attributable to the leading risk factors in children younger than 5 years (A) and other age groups (B) in 2021 Charts represent DALYs in counts for children younger than 5 years (A) and those aged 5 years and older (B). Early neonatal represents newborns aged 0–6 days. Late neonatal represents newborns aged 7–27 days. Low birthweight is defined as any birthweight in 500 g units below the TMREL at 38 weeks or later but less than 40 weeks, and 3500 g or greater but less than 4000 g. Short gestation refers to any gestational age that falls below the gestational age TMREL at less than 37 completed weeks. Suboptimal breastfeeding includes the absence of breastmilk as a source of nourishment for children aged 6–23 months and the practice of non-exclusive breastfeeding among infants younger than 6 months. Child growth failure includes stunting, wasting, and underweight. DALY=disability-adjusted life-year. TMREL=theoretical minimum risk exposure level.
Figure 5
Figure 5
Number of diarrhoeal deaths (A) and DALYs (B) in specific age groups in children younger than 5 years attributable to 13 pathogens in 2021 Early neonatal represents newborns aged 0–6 days. Late neonatal represents newborns aged 7–27 days. DALY=disability-adjusted life-year. PAF=population attributable fraction. ST-ETEC=enterotoxigenic Escherichia coli producing heat-stable toxin. tEPEC=typical enteropathogenic E coli.
See this image and copyright information in PMC

References

    1. GBD 2019 Diseases and Injuries Collaborators Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–1222. - PMC - PubMed
    1. GBD 2016 Diarrhoeal Disease Collaborators Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018;18:1211–1228. - PMC - PubMed
    1. WHO. UNICEF Ending preventable child deaths from pneumonia and diarrhoea by 2025: the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) June 15, 2013. https://apps.who.int/iris/handle/10665/79200 - PubMed
    1. Okada K, Wongboot W, Kamjumphol W, et al. Etiologic features of diarrheagenic microbes in stool specimens from patients with acute diarrhea in Thailand. Sci Rep. 2020;10 - PMC - PubMed
    1. Ochoa TJ, Ecker L, Barletta F, et al. Age-related susceptibility to infection with diarrheagenic Escherichia coli among infants from Periurban areas in Lima, Peru. Clin Infect Dis. 2009;49:1694–1702. - PMC - PubMed