Multivariable Analysis of Acute Watery Diarrhea in Afghanistan: Demographic, Clinical, and Environmental Determinants (2023–2025)

Abstract

ABSTRACT

Background: Acute Watery Diarrhea (AWD) remains a major public health concern in Afghanistan, particularly among children under five years of age. Persistent humanitarian crises, fragile infrastructure, mass displacement, unsafe water supplies, and critically limited access to basic water, sanitation, and hygiene (WASH) services contribute to continued transmission. While the global link between inadequate WASH and diarrheal disease is established, responses in Afghanistan are hampered by a lack of detailed, context specific evidence on the interaction of specific risk factors. This study aimed to examine demographic, environmental, geographic, temporal, and clinical determinants of AWD using national surveillance data from 2023–2025.

Materials and Methods: A secondary analysis was conducted using national AWD surveillance data (N=31,180 cases, 2023–2025). Descriptive statistics summarized demographic, environmental, and clinical characteristics. Bivariate associations were tested using chi-square analysis, and statistical significance was defined at p<0.05.

Results: A total of 31,180 AWD cases were reported. Children under five accounted for 6,951 cases (22.29%), with males representing 52.08% of total cases. Seasonal peaks occurred from July to October (53.69%, 16,742 cases). Eastern provinces showed the highest burden. Nangarhar (4,932 cases, a total of 15.81%), Laghman (2,860 with total of 9.17%) and Kabul (2,516 cases with total of 8.06%), were high-burden provinces. Unimproved sanitation (56.24%) and open defecation (23.38%) were common among cases. Surface water use was strongly associated with severe dehydration signs (p<0.001). Clinically, vomiting (80.47%), fever (66.52%), sunken eyes (39.15%), very low skin turgor (33.02%), shock (3.48%), and blood in stool (10.60%) were observed. Severe dehydration markers were significantly associated with unimproved water and sanitation conditions (p<0.05).

Conclusion: AWD in Afghanistan follows clear demographic, environmental, and seasonal gradients. Unimproved sanitation and unsafe water sources are strongly associated with both occurrence and severity. Targeted WASH interventions, early case management, and strengthened surveillance are urgently required. This study provides the first multidimensional, multivariable risk profile for the Afghan context. Findings highlight the urgent need for targeted WASH interventions, enhanced surveillance, and community-engaged programming, with specific focus on children aged 6–23 months, surface water users, and crowded households.

Keywords: Acute Watery Diarrhea, Afghanistan, Conflict, Epidemiology, Multivariable Analysis Risk Factors, WASH