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Publication date: 
September 25, 2018


Shigella and enterotoxigenic Escherichia coli (ETEC) are bacterial pathogens that are frequently associated with diarrheal disease, and are a significant cause of mortality and morbidity worldwide. The Global Burden of Diseases, Injuries, and Risk Factors study 2016 (GBD 2016) is a systematic, scientific effort to quantify the morbidity and mortality due to over 300 causes of death and disability. We aimed to analyze the global burden of shigella and ETEC diarrhea according to age, sex, geography, and year from 1990 to 2016.


We modeled shigella and ETEC-related mortality using a Bayesian hierarchical modeling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We used a compartmental meta-regression tool to model the incidence of shigella and ETEC, which enforces an association between incidence, prevalence, and remission on the basis of scientific literature, population representative surveys, and health care data. We calculated 95% uncertainty intervals (UIs) for the point estimates.


Shigella was the second leading cause of diarrheal mortality in 2016 among all ages, accounting for 212,438 deaths (95% UI 136,979–326,913) and about 13.2% (9.2–17.4) of all diarrhea deaths. Shigella was responsible for 63,713 deaths (41,191–93,611) among children younger than 5 years and was frequently associated with diarrhea across all adult age groups, increasing in elderly people, with broad geographical distribution. ETEC was the eighth leading cause of diarrhea mortality in 2016 among all age groups, accounting for 51,186 deaths (26,757–83,064) and about 3.2% (1.8–4.7) of diarrhea deaths. ETEC was responsible for about 4.2% (2.2–6.8) of diarrhea deaths in children younger than 5 years.


The health burden of bacterial diarrheal pathogens is difficult to estimate. Despite existing prevention and treatment options, they remain a major cause of morbidity and mortality globally. Additional emphasis by public health officials is needed on a reduction in disease due to shigella and ETEC to reduce disease burden.


Khalil IA, Troeger C, Blacker BF, et al. Morbidity and mortality due to shigella and enterotoxigenic Escherichia coli diarrhoea: the Global Burden of Disease Study 1990–2016. The Lancet Infectious Diseases. 25 September 2018. doi:10.1016/S1473-3099(18)30475-4.