Background

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

Methods

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

Findings

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1–65·8), 17·4% (7·7–28·4), and 59·5% (34·2–86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

Interpretation

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

Funding

Bill & Melinda Gates Foundation.

中文翻译：

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绘制 2000-17 年低收入和中等收入国家儿童腹泻发病率和死亡率的地理不平等：2017 年全球疾病负担研究分析。

背景

在低收入和中等收入国家 (LMIC)，五岁以下儿童死亡中十分之一是由腹泻引起的。各国之间腹泻发病率和死亡率的巨大差异归因于保护儿童、预防感染和治疗疾病的干预措施。确定负担最重的次国家地区并绘制相关风险因素有助于减少可预防的儿童腹泻。

方法

我们使用基于贝叶斯模型的地统计学和地理定位数据集（包括 94 个中低收入国家的 466 项调查中的 15 072 746 名 5 岁以下儿童），并结合 2017 年全球疾病、伤害和风险因素负担研究 (GBD) 的结果，估计 2000 年至 2017 年腹泻患病率、发病率和死亡率的后验分布。根据这些数据，我们通过空间聚合绘制来估计不同国家以下各级（称为单位）的腹泻负担，并通过创建汇总数据来调查国家以下各级模式的驱动因素风险因素估计。

发现

南亚、东南亚和南美洲的腹泻死亡率下降幅度最大，其中 54·0%（95% 不确定性区间 [UI] 38·1–65·8）、17·4%（7·7–28· 4) 和 59·5% (34·2–86·9) 的单位分别记录腹泻死亡人数下降超过 10%。尽管非洲大部分地区的儿童仍然面临因腹泻而死亡的高风险，但死亡人数最多的地区位于非洲以外，其中死亡率最高的地区位于巴基斯坦。印度尼西亚表现出国内最大的地理不平等；一些区域的死亡率几乎是国家平均死亡率的四倍。死亡率的降低与水、环境卫生和个人卫生 (WASH) 的改善或儿童生长障碍 (CGF) 的减少相关。同样，大多数高风险地区的 WASH 较差、CGF 较高或口服补液治疗覆盖率较低。

解释

通过共同分析腹泻负担的地理空间趋势及其关键风险因素，我们可以评估地方性死亡减少的候选驱动因素。此外，通过使用关键风险因素对剩余疾病负担进行反事实分析，我们确定了针对弱势群体的潜在干预策略。鉴于中低收入国家对有限资源的需求，准确量化腹泻负担及其驱动因素对于精准公共卫生非常重要。

资金

比尔及梅琳达·盖茨基金会。