• Muhammad Hilmi Mahmud Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia
  • Zaleha Md. Isa Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia
Keywords: diarrhoea, vulnerable, environmental factors, Malaysia, review


Despite improvements in global public health, diarrhoea causes more than 1.65 million deaths in 2016 which placed diarrhoea as the eighth leading cause of mortality in all ages and placed the fifth leading cause of death in children age five years and below in Malaysia. The impact of frequent diarrhoeal episodes is tremendous especially to children which include stunting and cognitive delay. There are three types of diarrhoea depending on the symptoms which are acute watery diarrhoea, acute bloody diarrhoea (dysentery) and persistent diarrhoea. Diarrhoea is commonly caused by Rotavirus, Cryptosporidium, Shigella, and Enterotoxigenic Escherichia coli (ETEC). Infectious agents for diarrhoea differ by transmission route, however, the risk factors of diarrhoeal episode are widely ranged and interconnected with each other which need to be identified. Modifiable risk factors such as the surrounding environment must be identified and improved which in turn avoid diarrhoea episodes. In this review, we identify the latrine and sanitation, waste disposal, housing condition, existence of animals, water quality, personal hygiene, seasonality and food hygiene/safety as environmental risk factors of diarrhoea.


World Health Organisation. Diarrhoeal disease [Internet]. 2017 [cited 2020 Oct 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease.

Troeger C, Blacker BF, Khalil IA, Rao PC, Cao S, Zimsen SR, et al. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis [Internet]. 2018 Nov 1 [cited 2020 Oct 18];18(11):1211–28. Available from: http://dx.doi.org/10.1016/

Dadonaite B, Ritchie H. Diarrheal diseases [Internet]. OurWorldInData.org. 2018 [cited 2020 Oct 18]. Available from: https://ourworldindata.org/diarrheal-diseases#why-are-children-still-dying-from-diarrhea.

Richard SA, Black RE, Gilman RH, Guerrant RL, Kang G, Lanata CF, et al. Catch-up growth occurs after diarrhea in early childhood. J Nutr [Internet]. 2014 [cited 2021 Jul 5];144(6):965–71. Available from: /pmc/articles/PMC4018956/.

Checkley W, Epstein LD, Gilman RH, Cabrera L, Black RE. Effects of acute diarrhea on linear growth in Peruvian children. Am J Epidemiol [Internet]. 2003 Jan 15 [cited 2021 Jul 5];157(2):166–75. Available from: https://academic.oup.com/aje/article/157/2/166/89996.

Pinkerton R, Oriá RB, Lima AAM, Rogawski ET, Oriá MOB, Patrick PD, et al. Early childhood diarrhea predicts cognitive delays in later childhood independently of malnutrition. Am J Trop Med Hyg [Internet]. 2016 Nov 1 [cited 2021 Jul 5];95(5):1004–10. Available from: /pmc/articles/PMC5094207/.

Prüss-Üstün A, Wolf J, Bos R, Neira M. Preventing disease through healthy environments A global assessment of the burden of disease from environmental risks. 2016.

Centers for Disease Control and Prevention (US CDC). CDC | National Center for Environmental Health [Internet]. 2021 [cited 2021 Aug 2]. Available from: https://www.cdc.gov/nceh/.

Guandalini S, Frye RE, Tamer MA. Diarrhea: Practice Essentials, Background, Pathophysiology [Internet]. Medscape. 2020 [cited 2020 Oct 18]. Available from: https://emedicine.medscape.com/article/928598-overview#a6.

Malaysian Paediatric Association. Guidelines on the management of Acute Diarrhoea in Children 2011. Allergo J Int [Internet]. 2011;(24):7–10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4792347/pdf/40629_2015_Article_74.pdf.

Kotloff KL. The Burden and Etiology of Diarrheal Illness in Developing Countries. Pediatr Clin North Am [Internet]. 2017 [cited 2021 Jul 5];64(4):799–814. Available from: http://dx.doi.org/10.1016/j.pcl.2017.03.006.

Kirk MD, Pires SM, Black RE, Caipo M, Crump JA, Devleesschauwer B, et al. World Health Organization Estimates of the Global and Regional Disease Burden of 22 Foodborne Bacterial, Protozoal, and Viral Diseases, 2010: A Data Synthesis. PLoS Med [Internet]. 2015 [cited 2020 Oct 19];12(12). Available from: /pmc/articles/PMC4668831/?report=abstract.

Lakhan C, Badrie N, Ramsubhag A, Sundaraneedi K, Indar L. Burden and impact of acute gastroenteritis and foodborne pathogens in Trinidad and Tobago. J Heal Popul Nutr. 2013 Dec;31(4 SUPPL.1).

Van Cauteren D, De Valk H, Vaux S, Le Strat Y, Vaillant V. Burden of acute gastroenteritis and healthcare-seeking behaviour in France: A population-based study. Epidemiol Infect [Internet]. 2012 Apr [cited 2020 Oct 19];140(4):697–705. Available from: https://doi.org/10.1017/S0950268811000999.

Gurpreet K, Tee GH, Amal NM, Paramesarvathy R, Karuthan C. Incidence and determinants of acute diarrhoea in Malaysia: A population-based study. J Heal Popul Nutr. 2011;29(2):103–12.

Nwaoha AF, Ohaeri CC, Amaechi EC. Prevalence of diarrhoea, and associated risk factors, in children aged 0-5 years, at two hospitals in Umuahia, Abia, Nigeria. UNED Res J. 2017;9(1):7–14.

Kubota K, Kasuga F, Iwasaki E, Inagaki S, Sakurai Y, Komatsu M, et al. Estimating the burden of acute gastroenteritis and foodborne illness caused by Campylobacter, Salmonella, and Vibrio parahaemolyticus by using population-based telephone survey data, Miyagi Prefecture, Japan, 2005 to 2006 [Internet]. Vol. 74, Journal of Food Protection. J Food Prot; 2011 [cited 2020 Oct 19]. p. 1592–8. Available from: https://pubmed.ncbi.nlm.nih.gov/22004803/.

Azry F, Aziz A, Ahmad NA, Aznuddin M, Razak A, Omar M, et al. Prevalence of and factors associated with diarrhoeal diseases among children under five in Malaysia : a cross-sectional study 2016. BMC Public Health [Internet]. 2018;1(18):1–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288967/.

Workie GY, Akalu TY, Baraki AG. Environmental factors affecting childhood diarrheal disease among under-five children in Jamma district, South Wello zone, Northeast Ethiopia. BMC Infect Dis [Internet]. 2019 Sep 13 [cited 2020 Oct 14];19(1):804. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4445-x.

Sima LC, Ng R, Elimelech M. Modeling Risk Categories to Predict the Longitudinal Prevalence of Childhood Diarrhea in Indonesia. Am J Trop Med Hyg. 2013;89(5):884–91.

Centers for Disease Control and Prevention (US CDC). Sanitation & Hygiene Home | Global Water, Sanitation and Hygiene | Healthy Water | CDC [Internet]. 2017 [cited 2021 Sep 14]. Available from: https://www.cdc.gov/healthywater/global/sanitation/index.html.

Voth-Gaeddert LE, Jonah C, Momberg D, Ngandu B, Said-Mohamed R, Oerther DB, et al. Assessment of environmental exposure factors on child diarrhea and systemic inflammation in the Eastern Cape. Water Res [Internet]. 2020 Feb 1 [cited 2020 Oct 14];169:115244. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0043135419310188.

Choy SH, Al-Mekhlafi HM, Mahdy MAK, Nasr NN, Sulaiman M, Lim YAL, et al. Prevalence and associated risk factors of Giardia infection among indigenous communities in rural Malaysia. Sci Rep [Internet]. 2014 Nov 4 [cited 2020 Oct 14];4(1):1–9. Available from: www.nature.com/scientificreports.

Nasr NA, Al-Mekhlafi HM, Lim YAL, Elyana FN, Sady H, Atroosh WM, et al. A holistic approach is needed to control the perpetual burden of soil-transmitted helminth infections among indigenous schoolchildren in Malaysia. Pathog Glob Health [Internet]. 2020 Apr 2 [cited 2020 Oct 14];114(3):145–59. Available from: https://www.tandfonline.com/doi/abs/10.1080/20477724.2020.1747855.

The World Bank. What a Waste: Solid Waste Management in Asia. 1999.

Wasihun AG, Dejene TA, Teferi M, Marugán J, Negash L, Yemane D, et al. Risk factors for diarrhoea and malnutrition among children under the age of 5 years in the Tigray Region of Northern Ethiopia. Reifsnider EA, editor. PLoS One [Internet]. 2018 Nov 26 [cited 2020 Oct 19];13(11):e0207743. Available from: https://dx.plos.org/10.1371/journal.pone.0207743.

Sharizman S, Abdul S, Shah SA, Jeffree MS. Factors of Acute Diarrhoea among Children of Under Five Years Old in Sabah, Malaysia: A Case- Control Study. Indian J Public Heal Res Dev. 2020;11(03):1185–90.

Penakalapati G, Swarthout J, Delahoy MJ, McAliley L, Wodnik B, Levy K, et al. Exposure to Animal Feces and Human Health: A Systematic Review and Proposed Research Priorities. Environ Sci Technol [Internet]. 2017 Oct 17 [cited 2020 Oct 19];51(20):11537–52. Available from: https://pubs.acs.org/sharingguidelines.

Headey D, Nguyen P, Kim S, Rawat R, Ruel M, Menon P. Is exposure to animal feces harmful to child nutrition and health outcomes? A multicountry observational analysis [Internet]. Vol. 96, American Journal of Tropical Medicine and Hygiene. American Society of Tropical Medicine and Hygiene; 2017 [cited 2020 Oct 19]. p. 961–9. Available from: http://www.ajtmh.org/content/journals/10.4269/ajtmh.16-0270.

Bukenya GB, Nwokolo N. Compound hygiene, presence of standpipe and the risk of childhood diarrhoea in an urban settlement of papua new guinea. Int J Epidemiol [Internet]. 1991 Jun 1 [cited 2020 Oct 19];20(2):534–9. Available from: https://academic.oup.com/ije/article/20/2/534/672198.

Bahartha AS, Alezzi JI. Risk factors of diarrhea in children under 5 years in Al-Mukalla, Yemen. Saudi Med J [Internet]. 2015 [cited 2020 Oct 19];36(6):720–4. Available from: /pmc/articles/PMC4454907/?report=abstract.

Shahrul Anuar T, M. Al-Mekhlafi H, Abdul Ghani MK, Osman E, Mohd Yasin A, Nordin A, et al. Prevalence and Risk Factors Associated with Entamoeba histolytica/dispar/moshkovskii Infection among Three Orang Asli Ethnic Groups in Malaysia. Snounou G, editor. PLoS One [Internet]. 2012 Oct 25 [cited 2020 Sep 30];7(10):e48165. Available from: https://dx.plos.org/10.1371/journal.pone.0048165.

World Health Organisation. Drinking-water [Internet]. 2019 [cited 2020 Oct 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/drinking-water.

World Health Organization. Preventing diarrhoea through better water, sanitation and hygiene. World Heal Organ [Internet]. 2014;1–48. Available from: http://apps.who.int/iris/bitstream/10665/150112/1/9789241564823_eng.pdf?ua=1&ua=1.

Hussein H. Prevalence of Diarrhea and Associated Risk Factors in Children Under Five Years of Age in Northern Nigeria: A Secondary Data Analysis of Nigeria Demographic and Health Survey 2013. 2017;(May). Available from: https://www.diva-portal.org/smash/get/diva2:1106657/FULLTEXT01.pdf.

Cohen A, Colford JM. Effects of boiling drinking water on diarrhea and pathogen-specific infections in low- and middle-income countries: A systematic review and meta-analysis [Internet]. Vol. 97, American Journal of Tropical Medicine and Hygiene. American Society of Tropical Medicine and Hygiene; 2017 [cited 2020 Oct 2]. p. 1362–77. Available from: https://www.ajtmh.org/content/journals/10.4269/ajtmh.17-0190.

Käferstein FK. Perspectives Food safety: the fourth pillar in the strategy to prevent infant diarrhoea. Vol. 81, Bulletin of the World Health Organization. 2003.

Takanashi K, Chonan Y, To Quyen D, Cong Khan N, Poudel KC, Jimba M. Survey of Food-hygiene Practices at Home and Childhood Diarrhoea in Hanoi, Viet Nam [Internet]. Vol. 27, Source: Journal of Health. 2009 [cited 2020 Oct 19]. Available from: https://www.jstor.org/stable/23499831?seq=1&cid=pdf-

World Health Organization. Personal, domestic and community hygiene. Heal Villagers A Guid Communities Community Heal Work [Internet]. 2004;65–73. Available from: https://www.who.int/water_sanitation_health/hygiene/settings/hvchap8.pdf.

Al-Delaimy AK, Al-Mekhlafi HM, Nasr NA, Sady H, Atroosh WM, Nashiry M, et al. Epidemiology of Intestinal Polyparasitism among Orang Asli School Children in Rural Malaysia. Taylan Ozkan A, editor. PLoS Negl Trop Dis [Internet]. 2014 Aug 21 [cited 2020 Oct 14];8(8):e3074. Available from: https://dx.plos.org/10.1371/journal.pntd.0003074.

Chao DL, Roose A, Roh M, Kotloff KL, Proctor JL. The seasonality of diarrheal pathogens: A retrospective study of seven sites over three years. PLoS Negl Trop Dis [Internet]. 2019 [cited 2021 Sep 15];13(8):e0007211. Available from: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0007211.

JV P, NJ H, DD M. Seasonal effects on the reported incidence of acute diarrhoeal disease in northeast Thailand. Int J Epidemiol [Internet]. 1991 Sep [cited 2021 Sep 15];20(3):777–86. Available from: https://pubmed.ncbi.nlm.nih.gov/1955264/.

Musengimana G, Mukinda FK, Machekano R, Mahomed H. Temperature Variability and Occurrence of Diarrhoea in Children under Five-Years-Old in Cape Town Metropolitan Sub-Districts. Int J Environ Res Public Health [Internet]. 2016 Sep 1 [cited 2021 Sep 15];13(9). Available from: /pmc/articles/PMC5036692/.

Aik J, Ong J, Ng LC. The effects of climate variability and seasonal influence on diarrhoeal disease in the tropical city-state of Singapore – A time-series analysis. Int J Hyg Environ Health. 2020 Jun 1;227:113517.

WHO Regional Office for Africa. Hygiene [Internet]. 2020 [cited 2020 Oct 21]. Available from: https://www.afro.who.int/health-topics/hygiene.

Zakaria LN, Minhat HS. Sociodemographic determinants of good hygience practices among the indigenous primary caregivers of under three children in Malaysia. Malaysian J Med Heal Sci. 2020;16(1):215–20.

How to Cite
Muhammad Hilmi Mahmud, & Md. Isa, Z. (2022). ENVIRONMENTAL RISK FACTORS OF DIARRHOEA AMONG VULNERABLE POPULATION: A NARRATIVE REVIEW. Malaysian Journal of Public Health Medicine, 22(2), 165-175. https://doi.org/10.37268/mjphm/vol.22/no.2/art.1372