Rotavirus Still Leads Child Diarrhea Hospitalizations Across 31 Countries, Surveillance Finds

Rotavirus remained the leading cause of diarrhea requiring hospitalization among children under five years of age in low- and middle-income countries between 2017 and 2022, even as its share of cases steadily declined, according to findings from the Global Pediatric Diarrhea Surveillance (GPDS) network, a World Health Organization-coordinated public health surveillance program.

During the six-year surveillance period, the network enrolled 70,750 children under five who were hospitalized with diarrhea.

By raw detection, rotavirus was the most prevalent pathogen found, with a weighted prevalence of 30.4 percent regardless of quantity or modeled attribution. It was followed by adenovirus 40/41 at 19.1 percent, norovirus at 17.9 percent, Shigella at 14.1 percent, and Campylobacter jejuni/coli at 8.6 percent. But when the team modeled which pathogen was actually responsible for each child’s illness, rotavirus again topped the list: across 2017–2022 it accounted for an attributable fraction of 32.5 percent (95 percent confidence interval: 27.4 to 37.6) of hospitalized diarrhea globally, followed by Shigella at 9.8 percent (8.4 to 11.3), adenovirus 40/41 at 8.6 percent (6.3 to 10.8), and norovirus at 6.7 percent (5.6 to 7.7).

The temporal trends were striking. The rotavirus attributable fraction fell consistently over the study window, from 36.7 percent (95 percent CI: 28.7 to 46.7) in 2017–2018 to 26.7 percent (20.7 to 34.1) in 2021–2022. Norovirus edged upward over the same span, from 6.2 percent (4.7 to 7.7) to 7.3 percent (5.0 to 9.2). The Shigella burden remained stable globally, while adenovirus 40/41 showed significant volatility, peaking worldwide in 2019–2020 at 11.9 percent (5.9 to 17.5).

Geography mattered as well. In 2021–2022, rotavirus was the leading cause of hospitalized diarrhea in six of nine geographic groupings, but norovirus predominated in Central and South America, and Shigella was the leading etiology in South Asia. These regional contrasts underscore that the mix of pathogens driving severe childhood diarrhea is far from uniform across the countries covered by the network.

The role of vaccination was also evident in the data. In the subset of countries that had introduced rotavirus vaccine, the leading etiologies of hospitalized diarrhea in 2021–2022 were rotavirus itself, at an attributable fraction of 18.4 percent (15.8 to 21.5), and Shigella, at 16.4 percent (11.8 to 21.1).

Measured as incidence, rotavirus also carried the heaviest burden in 2021–2022, with an attributable incidence of hospitalized diarrhea of 2.3 per 1,000 child-years (95 percent CI: 1.8 to 3.0). Shigella followed at 0.9 per 1,000 child-years (0.7 to 1.1), with norovirus and adenovirus 40/41 each at 0.6 per 1,000 child-years (0.4 to 0.8). These estimates quantify how many hospitalizations each pathogen causes per child-year of observation, providing a common metric for comparing pathogens and prioritizing interventions.

Despite the widespread use of rotavirus vaccines, the study concluded that rotavirus remained the leading cause of severe diarrhea among children under five in low- and middle-income countries globally. At the same time, the proportion of pediatric diarrhea attributable to rotavirus consistently declined from 2017–2018 through 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.

The authors note that improving the efficacy and coverage of rotavirus vaccination, and prioritizing interventions against other enteric pathogens, could further reduce diarrhea morbidity and mortality. As diarrhea remains a leading cause of child morbidity and mortality worldwide, ongoing surveillance of this kind is intended to help health authorities prioritize and evaluate the use of existing and upcoming vaccines and interventions against the pathogens that continue to hospitalize young children across the 31 countries in the network.

Subject of Research: Etiology and incidence of diarrhea requiring hospitalization in children under five in low- and middle-income countries, 2017–2022

Article 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

Article References: Soeters, H. M., Antoni, S., Iyer, S. S., Weldegebriel, G., Biey, J., Mwenda, J. M., Rey-Benito, G., Ortiz, C., Pastore, R., Videbaek, D., Singh, S., Njambe, E., Sangal, L., Dhongde, D., Grabovac, V., Logronio, J., Fahmy, K., Ghoniem, A., Armah, G., … for the Global Pediatric Diarrhea Surveillance network (2026). 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. PLOS Global Public Health, 6(10), e0006655. https://doi.org/10.1371/journal.pgph.0006655

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0006655

Keywords: rotavirus, diarrhea, children under five, hospitalization, Shigella, norovirus, adenovirus 40/41, low- and middle-income countries, Global Pediatric Diarrhea Surveillance, attributable fraction, rotavirus vaccine, qPCR surveillance