Global significance of diarrheal disorders and persistent diarrhea

Despite considerable advances in the understanding and management of diarrheal disorders in childhood, they are still responsible for a major burden of childhood deaths globally, with an estimated 2.5 million deaths.1 In an estimate of the global burden of diarrheal disorders in 1980 the World Health Organization (WHO) calculated that there were over 700 million episodes of diarrhea annually in children under 5 years of age in developing countries (excluding China), with approximately 4.6 million deaths.2 Reviews in the early 1990s suggested that diarrheal disorders still accounted for almost a third of all admissions to health facilities in developing countries,3 with an estimated incidence of diarrheal disorders at around 2.6 episodes/child per year. More recent reviews of studies published in the past 10 years indicate that, while global mortality may have reduced, the incidence remained unchanged at about 3.2 episodes/child year.4,5 These findings indicate the continuing need to focus on prevention and management of childhood diarrhea in developing countries.

It is recognized that most diarrheal disorders form a continuum, with the majority of cases resolving within the first week of the illness. However, a smaller proportion of diarrheal illnesses fail to resolve and may persist for longer than 2 weeks. Persistent diarrhea has been defined as an episode that begins acutely but lasts for 14 days or longer. It has been shown to identify children with a substantially increased diarrheal burden and leads to the majority of all diarrhea-related deaths.6 In a prospective study of diarrheal disorders in north India, persistent diarrhea accounted for only 5% of all diarrheal episodes, but the case/fatality rate for persistent diarrhea was 14% in comparison with 0.7% for episodes of shorter duration.7 In a similar prospective study of diarrheal episodes in the community in and around Lahore (Pakistan), persistent diarrhea accounted for 8-18% of all diarrheal episodes but 54% of all diarrheal deaths.8 Figure 12.1 indicates the relative proportion of diarrheal episodes from several prospective community-based studies in developing coun-tries.7,9-11

It is important to emphasize that the bulk of the epidemiological information on the relationship of acute diarrheal disorders to persistent diarrhea is derived from studies undertaken over 10-15 years ago, and that there is a paucity of recent data on this subject, especially from areas non-endemic for HIV.5 However, it is evident from studies in HIV-endemic areas that chronic enteropathy and persistent diarrhea is a common manifestation of advancing HIV infection and AIDS.

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