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Diarrhoeal disease

Fact sheet N330

April 2013

Key facts

Diarrhoeal disease is the second leading cause of death in children under five years
old. It is both preventable and treatable.

Each year diarrhoea kills around 760 000 children under five.

A significant proportion of diarrhoeal disease can be prevented through safe drinking-

water and adequate sanitation and hygiene.

Globally, there are nearly 1.7 billion cases of diarrhoeal disease every year.

Diarrhoea is a leading cause of malnutrition in children under five years old.

Diarrhoeal disease is the second leading cause of death in children under five years old, and
is responsible for killing around 760 000 children every year. Diarrhoea can last several days,
and can leave the body without the water and salts that are necessary for survival. Most
people who die from diarrhoea actually die from severe dehydration and fluid loss. Children
who are malnourished or have impaired immunity as well as people living with HIV are most
at risk of life-threatening diarrhoea.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more
frequent passage than is normal for the individual). Frequent passing of formed stools is not
diarrhoea, nor is the passing of loose, "pasty" stools by breastfed babies.

Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by
a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated
food or drinking-water, or from person-to-person as a result of poor hygiene.

Interventions to prevent diarrhoea, including safe drinking-water, use of improved sanitation

and hand washing with soap can reduce disease risk. Diarrhoea can be treated with a solution
of clean water, sugar and salt, and with zinc tablets.

There are three clinical types of diarrhoea:

acute watery diarrhoea lasts several hours or days, and includes cholera;

acute bloody diarrhoea also called dysentery; and

persistent diarrhoea lasts 14 days or longer.

Scope of diarrhoeal disease

Diarrhoeal disease is a leading cause of child mortality and morbidity in the world, and
mostly results from contaminated food and water sources. Worldwide, 780 million
individuals lack access to improved drinking-water and 2.5 billion lack improved sanitation.
Diarrhoea due to infection is widespread throughout developing countries.

In developing countries, children under three years old experience on average three episodes
of diarrhoea every year. Each episode deprives the child of the nutrition necessary for growth.
As a result, diarrhoea is a major cause of malnutrition, and malnourished children are more
likely to fall ill from diarrhoea.


The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water
and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools,
vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced.

The degree of dehydration is rated on a scale of three.

Early dehydration no signs or symptoms.

Moderate dehydration:

o thirst

o restless or irritable behaviour

o decreased skin elasticity

o sunken eyes

Severe dehydration:

o symptoms become more severe

o shock, with diminished consciousness, lack of urine output, cool, moist

extremities, a rapid and feeble pulse, low or undetectable blood pressure, and
pale skin.

Death can follow severe dehydration if body fluids and electrolytes are not replenished, either
through the use of oral rehydration salts (ORS) solution, or through an intravenous drip.

Infection: Diarrhoea is a symptom of infections caused by a host of bacterial, viral and
parasitic organisms, most of which are spread by faeces-contaminated water. Infection is
more common when there is a shortage of adequate sanitation and hygiene and safe water for
drinking, cooking and cleaning. Rotavirus and Escherichia coli are the two most common
etiological agents of diarrhoea in developing countries.

Malnutrition: Children who die from diarrhoea often suffer from underlying malnutrition,
which makes them more vulnerable to diarrhoea. Each diarrhoeal episode, in turn, makes
their malnutrition even worse. Diarrhoea is a leading cause of malnutrition in children under
five years old.

Source: Water contaminated with human faeces, for example, from sewage, septic tanks and
latrines, is of particular concern. Animal faeces also contain microorganisms that can cause

Other causes: Diarrhoeal disease can also spread from person-to-person, aggravated by poor
personal hygiene. Food is another major cause of diarrhoea when it is prepared or stored in
unhygienic conditions. Water can contaminate food during irrigation. Fish and seafood from
polluted water may also contribute to the disease.

Prevention and treatment

Key measures to prevent diarrhoea include:

access to safe drinking-water;

use of improved sanitation;

hand washing with soap;

exclusive breastfeeding for the first six months of life;

good personal and food hygiene;

health education about how infections spread; and

rotavirus vaccination.

Key measures to treat diarrhoea include the following:

Rehydration: with oral rehydration salts (ORS) solution. ORS is a mixture of clean
water, salt and sugar. It costs a few cents per treatment. ORS is absorbed in the small
intestine and replaces the water and electrolytes lost in the faeces.

Zinc supplements: zinc supplements reduce the duration of a diarrhoea episode by

25% and are associated with a 30% reduction in stool volume.

Rehydration: with intravenous fluids in case of severe dehydration or shock.

Nutrient-rich foods: the vicious circle of malnutrition and diarrhoea can be broken by
continuing to give nutrient-rich foods including breast milk during an episode, and
by giving a nutritious diet including exclusive breastfeeding for the first six months
of life to children when they are well.

Consulting a health professional , in particular for management of persistent diarrhoea

or when there is blood in stool or if there are signs of dehydration.

WHO response

WHO works with Member States and other partners to:

promote national policies and investments that support case management of diarrhoea
and its complications as well as increasing access to safe drinking-water and
sanitation in developing countries;

conduct research to develop and test new diarrhoea prevention and control strategies
in this area;

build capacity in implementing preventive interventions, including sanitation, source

water improvements, and household water treatment and safe storage;

develop new health interventions, such as the rotavirus immunization; and

help to train health workers, especially at community level.

23/1/2015 8.58

Diarrhea kills 2,195 children every daymore than AIDS, malaria, and measles
combined 1.

Diarrheal diseases account for 1 in 9 child deaths worldwide, making diarrhea the second
leading cause of death among children under the age of 5. For children with HIV, diarrhea is
even more deadly; the death rate for these children is 11 times higher than the rate for
children without HIV 2. Despite these sobering statistics, strides made over the last 20 years
have shown that, in addition to rotavirus vaccination and breastfeeding, diarrhea prevention
focused on safe water and improved hygiene and sanitation is not only possible, but cost
effective: every $1 invested yields an average return of $25.50 3.

Learn how simple and inexpensive interventions to prevent and treat diarrhea can save the
lives of children around the world.
$1 invested in diarrhea prevention yields an average return of $25.50.

Stopping Diarrhea

Most diarrheal deaths are preventable using simple, low-cost interventions.

Diarrhea: What we know

It causes death by depleting body fluids resulting in profound dehydration.

Diarrhea can have a detrimental impact on childhood growth and cognitive

development 4.

About 88% of diarrhea-associated deaths are attributable to unsafe water,

inadequate sanitation, and insufficient hygiene 5, 6.

Rotavirus is the leading cause of acute diarrhea and causes about 40% of
hospitalizations for diarrhea in children under 5 7.

Most diarrheal germs are spread from the stool of one person to the mouth
of another. These germs are usually spread through contaminated water,
food, or objects.

Water, food, and objects become contaminated with stool in many ways:

o People and animals defecate in or near water sources that people


o Contaminated water is used to irrigate crops.

o Food preparers do not wash their hands before cooking.

o People with contaminated hands touch objects, such as doorknobs,

or cooking utensils.
Diarrhea kills more children than malaria, measles, and AIDS combined. Proportional
distribution of cause-specific deaths among children under five years of age, 2012 (excluding
neonatal deaths) 1.

Diarrhea: Proven Ways to Save Lives

Vaccinate for rotavirus


o Safe water

o Adequate sanitation and human waste disposal


o Handwashing with soap

o Breastfeeding to reduce exposure to contaminated water

Treat appropriately with oral rehydration therapy and antibiotics

Train health care providers and community health workers on diarrhea


Educate mothers and caretakers about caring for ill children and when to
seek medical assistance

Build laboratory diagnostic capability and identify the causes of diarrhea

Top of Page

Pathways to Diarrhea
Pathways to Diarrhea. Illustrates how contamination can occur. Click to enlarge.

What Can Be Done

Use effective interventions and proven treatment for diarrhea.

Governments and ministries of health can:

Provide rotavirus vaccination

Invest in safe drinking water, hygiene, and sanitation infrastructure

Monitor progress and needs through the collection, analysis, and reporting
of quality data

Support clear and targeted health promotion and behavior change

Non-governmental/aid organizations can:

Increase the adoption of proven measures against diarrhea

o Rotavirus vaccination

o Breastfeeding

o Oral rehydration therapy

o Household and community systems for treating and storing water

Educate communities on the importance of safe water, sanitation, and


Enhance and support government initiatives that invest in safe drinking

water, sanitation, and hygiene infrastructure

Ensure the sustainability of interventions

Focus on the provision of safe water, sanitation, and hygiene when

responding to emergency and conflict situations

Health care providers and clinical facilities can:

Ensure availability of adequate medical supplies such as oral rehydration


Improve training programs for health workers and educate them on the
proper treatment of diarrhea

Ensure that facilities for handwashing, provision of safe water, and proper
disposal of human waste are provided at ALL healthcare facilities

Encourage appropriate antibiotic use

Meet demand for health workers

Support community health workers

o Improve training programs

o Seek creative ways to motivate them

Communities can:

Support and promote the importance of community health workers

Ensure safe water is provided close to peoples homes

Discourage/eliminate open defecation

Develop strategies for proper disposal of human waste

Construct basic sanitation facilities

Promote handwashing

Preventing Diarrhea, Saving Lives

Safe water/adequate sanitation: Treat water before use and dispose of waste safely.

Improved hygiene: Wash hands when appropriate.

Routine vaccination: Provide rotavirus vaccine.


1. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell
H, Cibulskis R, Li M, Mathers C, Black RE; Child Health Epidemiology
Reference Group of WHO and UNICEF. Global, regional, and national causes
of child mortality: an updated systematic analysis for 2010 with time
trends since 2000. Lancet. 2012;379(9832):2151-61.

2. Hutton G, Haller L, Bartram J. Global cost-benefit analysis of water supply

and sanitation interventions. J Water Health. 2007;5(4):481-502.

3. Tindyebwa D et al. Common clinical conditions associated with HIV.

Handbook on Paediatric AIDS in Africa. 2004.

4. Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra RM.

Association between intensive handwashing and child development in
Karachi, Pakistan: A cluster controlled trial. Arch Pediatr Adolesc Med.
2012 Sep; [Epub ahead of print]

5. UNICEF. Progress for children: A report card on water and sanitation.

Number 5, September 2006.

6. Black RE, Morris S, Bryce J. Where and why are 10 million children dying
every year? Lancet. 2003;361(9376):2226-34.

7. WHO. Weekly epidemiological record. [PDF - 8 pages]