Deaths from infections that cause diarrhoea and other intestinal illnesses have fallen sharply since 1990, thanks in part to the rotavirus vaccine, among other factors, according to a study published in The Lancet Infectious Diseases.
CIDRAP News reports that using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, an international team of researchers examined mortality from enteric infectious diseases across 204 countries and territories from 1990 to 2023.
The category included diarrhoeal disease, invasive non-typhoidal Salmonella (iNTS) infections, enteric fever (typhoid and paratyphoid), and other intestinal infectious diseases, which are typically transmitted through the faecal-oral route by contaminated food, water, or hands and can be highly contagious.
Their analysis found that the number of global deaths from enteric infectious diseases fell from 3.69m in 1990 to 1.27m in 2023, and the global age-standardised mortality rate fell from 74.1 per 100 000 to 16.4.
Rotavirus vaccine makes big impact
Diarrhoeal disease accounted for most of the deaths in 2023 (1.11m), followed by enteric fever and iNTS infections. Rotavirus was the leading cause of diarrhoeal disease (16.3%), followed by norovirus (10.2%) and Shigella (9.3%).
Asia (599 00) and sub-Saharan Africa (501 000) had the largest number of deaths from enteric infectious diseases in 2023.
Researchers with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington were among the dozens of scientists involved in the study, which was funded by the Gates Foundation. They say the reductions are the result of multiple overlapping preventive measures aimed at enteric infections, including increased access to rotavirus vaccines, which is up to 98% effective against severe illness in infants in high-income countries.
“The leading pathogen driving diarrhoeal deaths among children in 1990-2023 was rotavirus, of which deaths were greatly reduced by global introduction of rotavirus vaccination in 2006,” Hmwe Hmwe Kyu, MBBS, MPH, PhD, an associate Professor in the department of Health Metrics Sciences at UW School of Medicine and IHME, told CIDRAP News.
Other factors include increased access to oral rehydration salts, which quickly replenish fluids in people with diarrhoea, and clean drinking water.
“While these are the main driving forces influencing the reduction in deaths due to enteric infectious diseases, there are other factors that contribute, like improved access to zinc treatment and safer access to toilets,” Kyu said.
Children under five disproportionately affected
While mortality fell across all age-groups, young children saw significant reductions. Kyu noted that in 1990, children under five made up roughly 53% of deaths from enteric infectious diseases. By 2023, that number had fallen to 30%.
Still, an estimated 317 000 children under five died from diarrhoeal disease in 2023. More than 70% of those deaths were in sub-Saharan Africa. And more than a quarter of the countries failed to meet the global target for diarrhoeal disease deaths in children under five (fewer than 20 deaths per 100 000 population by 2025), the researchers found.
Kyu said higher rotavirus vaccine coverage could help further reduce childhood deaths from diarrhoea. In the 63 countries that failed to meet the target, she said, rotavirus is consistently one of the higher causes of under-five diarrhoea deaths.
Progress under threat
Kyu and her colleagues also noted that reductions in global health financing, the changing geographic landscape of key enteric pathogens because of climate change, and a rise in drug-resistant bacteria – which limits the effectiveness of treatments for bacterial enteric infections – all pose a threat to that progress.
“The compilation of these challenges casts uncertainty over the sustainability and future direction of global enteric disease prevention and control efforts,” they wrote.
Kyu said it’s possible that deaths from enteric infectious disease could plateau in the coming years, or even increase, because of these factors. But she also pointed to some hopeful signs, including the rollout of rotavirus vaccination in countries like Vietnam, Iran, and Somalia, and recently announced World Bank funding for a programme to improve access to clean water, sanitation, and hygiene in eastern and southern Africa.
“With these more encouraging developments, it is possible that deaths due to enteric infectious diseases will continue to decrease,” she said.
Study details
Global burden of enteric infectious diseases, diarrhoeal diseases, and corresponding aetiologies, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023
GBD 2023 Diarrhoeal Disease and Enteric Infectious Diseases Collaborators†
Published in The Lancet Infectious Diseases on 11 June 2026
Summary
Background
Enteric infectious diseases claim more than 1 million lives annually and are among the top ten causes of death in children younger than 5 years. Remarkable global investment has been dedicated to enteric infectious disease prevention and control; however, the shifting global health landscape is testing the continuance of progress. To evaluate the current status and guide future interventions, we present the latest epidemiological estimates of enteric infectious diseases from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 and assess progress towards the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) mortality target of fewer than 20 deaths per 100 000 children younger than 5 years by 2025.
Methods
We quantified the incidence, mortality, and disability-adjusted life-years (DALYs) of enteric infectious diseases by age, sex, and year across 204 countries and territories from 1990 to 2023. In GBD 2023, the following were considered under the category of enteric infectious diseases: diarrhoeal diseases, enteric fever (typhoid and paratyphoid), invasive non-typhoidal Salmonella spp (iNTS) infections, and other intestinal infectious diseases. We also examined 15 aetiologies contributing to diarrhoeal diseases. Incidence and prevalence were estimated with DisMod-MR (version 2.1), a Bayesian meta-regression tool, drawing on data from systematic reviews, population-based surveys, claims data, and hospital sources. Cause-specific mortality was modelled with Cause of Death Ensemble Modelling based on data from sources including vital registration, mortality surveillance, verbal autopsy, and minimally invasive tissue sampling. Years of life lost and years lived with disability were computed and combined to derive DALYs. For aetiology-specific estimation, population-attributable fractions (PAFs) for 15 pathogens were derived with a counterfactual framework. Point estimates and 95% uncertainty intervals (UIs) were generated from 250 draws from the posterior distribution.
Findings
In 2023, enteric infectious diseases resulted in an estimated 1·27 million (95% UI 0·963–1·68) deaths globally, declining from 3·69 million (3·04–4·56) in 1990. The global age-standardised mortality rate (ASMR) decreased from 74·1 (62·0–92·9) per 100 000 population to 16·4 (12·6–21·3) per 100 000 population during the same period. Diarrhoeal diseases accounted for most deaths in 2023 (1·11 million [0·811–1·54]), followed by enteric fever and iNTS. South Asia and sub-Saharan Africa remained the most affected regions in 2023, with 599 000 (441 000–882 000) and 501 000 (373 000–648 000) deaths due to enteric infectious diseases, respectively, predominantly from diarrhoeal disease. Rotavirus was the leading cause of all-age diarrhoeal disease deaths (PAF 16·3% [12·0–21·5]), followed by norovirus (10·2% [2·4–17·0]) and Shigella spp (9·3% [5·4–15·2]). Among children younger than 5 years, PAFs of deaths due to diarrhoeal diseases were 40·2% (32·5–48·5) for rotavirus, 24·0% (15·1–36·7) for Shigella spp, and 23·4% (13·7–34·3) for adenovirus. Across 204 countries and territories, 141 met the GAPPD mortality target in 2023. The driving aetiologies among countries that did not meet the target in 2023 varied slightly by GBD super-region, but the highest or second-highest number of deaths in children younger than 5 years were consistently attributed to rotavirus. Astrovirus and sapovirus, newly included in GBD 2023, were responsible for 24 600 (6290–49 000) and 18 800 (4650–44 400) deaths, respectively, in 2023, mainly in children younger than 5 years.
Interpretation
Our findings show that mortality and ASMRs of enteric infectious diseases declined substantially between 1990 and 2023. This decline is consistent with the expansion of public health measures and broader socioeconomic development. However, the burden in 2023 remains considerably high, with the highest mortality concentrated in sub-Saharan Africa and south Asia. Considering that more than a quarter of all countries had yet to meet the GAPPD mortality target in 2023, sustained efforts are needed to address the persistent burden in affected countries and to adapt to the changing global health landscape.
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