Etiology and incidence of diarrhea requiring hospitalization in children under 5 years of age in 31 low- and middle-income countries: Findings from the Global Pediatric Diarrhea Surveillance network, 2017–2022
18 affiliations
- 1World Health Organization, Geneva, Switzerland
- 2World Health Organization Regional Office for Africa, Brazzaville, Congo
- 3Pan American Health Organization, World Health Organization Regional Office for the Americas, Washington, District of Columbia, United States of America
- 4World Health Organization Regional Office for Europe, Copenhagen, Denmark
- 5World Health Organization Regional Office for South-East Asia, New Delhi, India
- 6World Health Organization Regional Office for the Western Pacific, Manila, Philippines
- 7World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
- 8Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, Ghana
- 9Diarrhoeal Pathogens Research Unit, Department of Virology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- 10Instituto Oswaldo Cruz Fiocruz, Rio de Janeiro, Brazil
- 11Republican Research and Practical Center for Epidemiology and Microbiology, Ministry of Health, Minsk, Belarus
- 12Christian Medical College, Vellore, India
- 13Murdoch Children’s Research Institute, Melbourne, Australia
- 14National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
- 15Infectious Diseases Research Laboratory, Aga Khan University, Karachi, Pakistan
- 16School of Public Health, Qingdao University, Qingdao, Shandong, China
- 17Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
- 18Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
Abstract
Diarrhea remains a leading cause of child morbidity and mortality. Improved and ongoing estimates of the etiology of hospitalized pediatric diarrhea in low- and middle-income countries (LMICs) are needed to help prioritize and evaluate the use of existing and upcoming vaccines and interventions. The Global Pediatric Diarrhea Surveillance (GPDS) network is a World Health Organization (WHO)-coordinated public health surveillance network investigating the etiology of hospitalized diarrhea among children aged <5 years in LMICs. The GPDS network enrolls children hospitalized with diarrhea at 38 sentinel surveillance sites in 31 LMICs. Randomly selected stool specimens were tested by TaqMan Array Card quantitative reverse-transcription polymerase chain reaction (qPCR) for 16 pathogens associated with diarrhea. We estimated pathogen-specific attributable fractions (AFs) and incidence of diarrheal hospitalizations at the global, regional, and country levels during 3 time periods: 2017–2018, 2019–2020, and 2021–2022, with a focus on the most recent results. During 2017–2022, the GPDS network enrolled 70,750 children aged <5 years hospitalized with diarrhea, of which 16,458 (23.3%) were randomly selected for qPCR testing. The most prevalent pathogen detected, regardless of quantity or modeled etiologic attribution, was rotavirus (weighted prevalence 30.4%), followed by adenovirus 40/41 (19.1%), norovirus (17.9%), Shigella (14.1%), and Campylobacter jejuni/coli (8.6%). Overall, in 2017–2022, rotavirus was the leading etiology globally (AF 32.5%; 95% Confidence Interval (CI): 27.4, 37.6), followed by Shigella (9.8%; 8.4, 11.3), adenovirus 40/41 (8.6%; 6.3, 10.8) and norovirus (6.7%; 5.6, 7.7). Over time, rotavirus consistently declined from an AF of 36.7% (95% CI: 28.7, 46.7) in 2017–2018 to 26.7% (20.7, 34.1) in 2021–2022. Norovirus AF increased slightly from 6.2% (4.7, 7.7) in 2017–2018 to 7.3% (5.0, 9.2) in 2021–2022. Global Shigella burden remained stable, and adenovirus 40/41 demonstrated significant volatility, peaking globally in 2019–2020 (11.9%; 5.9, 17.5). In 2021–2022, rotavirus was the leading cause of hospitalized diarrhea in 6 of 9 geographic groupings, norovirus predominated in Central and South America, and Shigella was the leading etiology in South Asia. In the subset of countries that had introduced rotavirus vaccine, the leading etiologies in 2021–2022 were rotavirus (18.4%; 15.8, 21.5) and Shigella (16.4%; 11.8, 21.1). In 2021–2022, rotavirus had the highest attributable incidence of hospitalized diarrhea in children (2.3 per 1,000 child-years; 1.8, 3.0), followed by Shigella (0.9; 0.7, 1.1), norovirus (0.6; 0.4, 0.8) and adenovirus 40/41 (0.6; 0.4, 0.8). Despite the widespread use of rotavirus vaccines, rotavirus remained the leading cause of severe diarrhea among children aged <5 years in LMICs globally. However, the proportion of pediatric diarrhea attributable to rotavirus consistently declined from 2017-2018–2021–2022, and there were notable differences in the distribution of diarrheal etiologies between regions and across time periods. Shigella, norovirus, and enteric adenoviruses were also associated with a substantial burden of disease. Improving the efficacy and coverage of rotavirus vaccination and prioritizing interventions against other enteric pathogens could further reduce diarrhea morbidity and mortality.
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BibTeX
@article{soeters2026etiology,
title = {{Etiology and incidence of diarrhea requiring hospitalization in children under 5 years of age in 31 low- and middle-income countries: Findings from the Global Pediatric Diarrhea Surveillance network, 2017–2022}},
author = {Heidi M. Soeters and Sébastien Antoni and Shilpa S. Iyer and Goitom Weldegebriel and Joseph Biey and Jason M. Mwenda and Gloria Rey-Benito and Claudia Ortiz and Roberta Pastore and Dovile Videbaek and Simarjit Singh and Emmanuel Njambe and Lucky Sangal and Deepak Dhongde and Varja Grabovac and Josephine Logronio and Kamal Fahmy and Amany Ghoniem and George Armah and Francis E. Dennis and Mapaseka L. Seheri and Nonkululeko Magagula and Kebareng Rakau-Nondela and Tulio M. Fumian and Irene T.A. Maciel and Elena Samoilovich and Galina Semeiko and Tintu Varghese and Sarah Thomas and Julie E. Bines and Dandi Li and Furqan Kabir and Jie Liu and Eric R. Houpt and Rashi Gautam and Sara A. Mirza and Jan Vinjé and Mick N. Mulders and Jacqueline E. Tate and Umesh D. Parashar and James A. Platts-Mills and for the Global Pediatric Diarrhea Surveillance network},
journal = {PLOS Global Public Health},
year = {2026},
month = oct,
doi = {10.1371/journal.pgph.0006655},
url = {https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0006655},
note = {CC0},
}
RIS
TY - JOUR
TI - Etiology and incidence of diarrhea requiring hospitalization in children under 5 years of age in 31 low- and middle-income countries: Findings from the Global Pediatric Diarrhea Surveillance network, 2017–2022
AU - Heidi M. Soeters
AU - Sébastien Antoni
AU - Shilpa S. Iyer
AU - Goitom Weldegebriel
AU - Joseph Biey
AU - Jason M. Mwenda
AU - Gloria Rey-Benito
AU - Claudia Ortiz
AU - Roberta Pastore
AU - Dovile Videbaek
AU - Simarjit Singh
AU - Emmanuel Njambe
AU - Lucky Sangal
AU - Deepak Dhongde
AU - Varja Grabovac
AU - Josephine Logronio
AU - Kamal Fahmy
AU - Amany Ghoniem
AU - George Armah
AU - Francis E. Dennis
AU - Mapaseka L. Seheri
AU - Nonkululeko Magagula
AU - Kebareng Rakau-Nondela
AU - Tulio M. Fumian
AU - Irene T.A. Maciel
AU - Elena Samoilovich
AU - Galina Semeiko
AU - Tintu Varghese
AU - Sarah Thomas
AU - Julie E. Bines
AU - Dandi Li
AU - Furqan Kabir
AU - Jie Liu
AU - Eric R. Houpt
AU - Rashi Gautam
AU - Sara A. Mirza
AU - Jan Vinjé
AU - Mick N. Mulders
AU - Jacqueline E. Tate
AU - Umesh D. Parashar
AU - James A. Platts-Mills
AU - for the Global Pediatric Diarrhea Surveillance network
PY - 2026
DA - 2026/10/27
JO - PLOS Global Public Health
DO - 10.1371/journal.pgph.0006655
UR - https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0006655
AB - Diarrhea remains a leading cause of child morbidity and mortality. Improved and ongoing estimates of the etiology of hospitalized pediatric diarrhea in low- and middle-income countries (LMICs) are needed to help prioritize and evaluate the use of existing and upcoming vaccines and interventions. The Global Pediatric Diarrhea Surveillance (GPDS) network is a World Health Organization (WHO)-coordinated public health surveillance network investigating the etiology of hospitalized diarrhea among children aged <5 years in LMICs. The GPDS network enrolls children hospitalized with diarrhea at 38 sentinel surveillance sites in 31 LMICs. Randomly selected stool specimens were tested by TaqMan Array Card quantitative reverse-transcription polymerase chain reaction (qPCR) for 16 pathogens associated with diarrhea. We estimated pathogen-specific attributable fractions (AFs) and incidence of diarrheal hospitalizations at the global, regional, and country levels during 3 time periods: 2017–2018, 2019–2020, and 2021–2022, with a focus on the most recent results. During 2017–2022, the GPDS network enrolled 70,750 children aged <5 years hospitalized with diarrhea, of which 16,458 (23.3%) were randomly selected for qPCR testing. The most prevalent pathogen detected, regardless of quantity or modeled etiologic attribution, was rotavirus (weighted prevalence 30.4%), followed by adenovirus 40/41 (19.1%), norovirus (17.9%), Shigella (14.1%), and Campylobacter jejuni/coli (8.6%). Overall, in 2017–2022, rotavirus was the leading etiology globally (AF 32.5%; 95% Confidence Interval (CI): 27.4, 37.6), followed by Shigella (9.8%; 8.4, 11.3), adenovirus 40/41 (8.6%; 6.3, 10.8) and norovirus (6.7%; 5.6, 7.7). Over time, rotavirus consistently declined from an AF of 36.7% (95% CI: 28.7, 46.7) in 2017–2018 to 26.7% (20.7, 34.1) in 2021–2022. Norovirus AF increased slightly from 6.2% (4.7, 7.7) in 2017–2018 to 7.3% (5.0, 9.2) in 2021–2022. Global Shigella burden remained stable, and adenovirus 40/41 demonstrated significant volatility, peaking globally in 2019–2020 (11.9%; 5.9, 17.5). In 2021–2022, rotavirus was the leading cause of hospitalized diarrhea in 6 of 9 geographic groupings, norovirus predominated in Central and South America, and Shigella was the leading etiology in South Asia. In the subset of countries that had introduced rotavirus vaccine, the leading etiologies in 2021–2022 were rotavirus (18.4%; 15.8, 21.5) and Shigella (16.4%; 11.8, 21.1). In 2021–2022, rotavirus had the highest attributable incidence of hospitalized diarrhea in children (2.3 per 1,000 child-years; 1.8, 3.0), followed by Shigella (0.9; 0.7, 1.1), norovirus (0.6; 0.4, 0.8) and adenovirus 40/41 (0.6; 0.4, 0.8). Despite the widespread use of rotavirus vaccines, rotavirus remained the leading cause of severe diarrhea among children aged <5 years in LMICs globally. However, the proportion of pediatric diarrhea attributable to rotavirus consistently declined from 2017-2018–2021–2022, and there were notable differences in the distribution of diarrheal etiologies between regions and across time periods. Shigella, norovirus, and enteric adenoviruses were also associated with a substantial burden of disease. Improving the efficacy and coverage of rotavirus vaccination and prioritizing interventions against other enteric pathogens could further reduce diarrhea morbidity and mortality.
SN - 2767-3375
ER -