Regional and national burden and etiological patterns of diarrheal disease in Asia with implications for travel...

Despite the considerable burden of diarrheal disease in Asia, etiology-specific patterns remain insufficiently characterized. This study aimed to provide a comprehensive assessment of the diarrheal disease burden across Asia from 1990 to 2023, focusing on the implications for travelers' diarrhea.

We estimated the burden of diarrheal disease in Asia, including Central, East, South, Southeast Asia, and High-income Asia Pacific, across 34 countries from 1990 to 2023 using the Global Burden of Diseases Study 2023. Disease burden was calculated using age-standardized disability-adjusted life year rates (ASDRs) per 100,000 population, with 95% uncertainty intervals (UIs). Additionally, we assessed the burden attributable to risk factors and calculated pathogen-specific estimates for 13 major etiologies.

From 1990 to 2023, ASDRs of diarrheal disease declined across Asia, with the largest decline in South Asia from 9124.29 (95% UI, 7594.46-11,673.82) per 100,000 population to 1216.90 (965.73-1633.55). The decline was accompanied by reductions in cumulative etiologic burden, particularly for rotavirus. Although norovirus was the leading etiology in High-income Asia Pacific, rotavirus remained dominant across all other Asian regions in 2023. Burdens were concentrated among those aged <5 years and ≥95 years. Among children aged <5 years, rotavirus and adenovirus were the leading etiologies, with adenovirus showing a particularly high age-specific DALY rate in South Asia (891.96 [484.65-1392.81] per 100,000 population). Among adults aged ≥ 95years, Clostridium difficile and norovirus had the highest burdens. Sex-specific burdens were generally higher in males, except in South Asia. In 2023, unsafe water sources were the leading risk factor, especially in South Asia, 831.77 (423.32-1206.25) per 100,000 population. For viral, parasitic, and gram-negative etiologies, burdens consistently declined with increasing SDI, whereas Clostridium difficile showed a U-shaped pattern with SDI.

The heterogeneity in etiology-specific burden, age- and sex-related vulnerability, and associations with SDI across Asia underscores the need for destination-specific risk assessment and context-sensitive prevention strategies for travelers' diarrhea in Asia.