{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T19:47:24Z","timestamp":1792784844407,"version":"4.5.0"},"reference-count":54,"publisher":"American Chemical Society (ACS)","issue":"6","license":[{"start":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T00:00:00Z","timestamp":1789603200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002858","name":"China Postdoctoral Science Foundation","doi-asserted-by":"publisher","award":["2023M732053"],"award-info":[{"award-number":["2023M732053"]}],"id":[{"id":"10.13039\/501100002858","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100015360","name":"State Key Laboratory of Infectious Disease Prevention and Control","doi-asserted-by":"publisher","award":["2018SKLID302"],"award-info":[{"award-number":["2018SKLID302"]}],"id":[{"id":"10.13039\/501100015360","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100010029","name":"Taishan Scholar Foundation of Shandong Province","doi-asserted-by":"publisher","award":["tsqn202306063"],"award-info":[{"award-number":["tsqn202306063"]}],"id":[{"id":"10.13039\/501100010029","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Natural Science Foundation of Shandong Province in China","award":["ZR2023QH319"],"award-info":[{"award-number":["ZR2023QH319"]}]},{"name":"Shandong Excellent Young Scientists Fund Program (Overseas)","award":["2022HWYQ-055"],"award-info":[{"award-number":["2022HWYQ-055"]}]},{"name":"National Natural Science Foundation of China (NSFC)","award":["42205179"],"award-info":[{"award-number":["42205179"]}],"id":[{"id":"https:\/\/ror.org\/01h0zpd94","id-type":"ROR","asserted-by":"crossref"}]},{"name":"National Natural Science Foundation of China (NSFC)","award":["82073615"],"award-info":[{"award-number":["82073615"]}],"id":[{"id":"https:\/\/ror.org\/01h0zpd94","id-type":"ROR","asserted-by":"crossref"}]},{"name":"National Natural Science Foundation of China (NSFC)","award":["82304200"],"award-info":[{"award-number":["82304200"]}],"id":[{"id":"https:\/\/ror.org\/01h0zpd94","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Background: Diarrhea in children is a climate-sensitive disease that causes a large disease burden worldwide, while the impact of El Nin\u0303o\u2013Southern Oscillation (ENSO) remains unclear. Objectives: This study aimed to evaluate the diarrhea risk among children associated with ENSO in low- and middle-income countries. Methods: Individual data on 1,340,334 children under five years of age were collected from 53 low- and middle-income countries from the Demographic and Health Surveys Program during 2005\u20132019, including information on diarrhea, demographic characteristics, cluster location, water, sanitation, and hygiene (WASH). ENSO indexes (E and C index) were calculated with sea surface temperature through Empirical Orthogonal Function analysis. Teleconnection (\u03c4E and \u03c4C) of the locations where the cluster sites were located was calculated based on population-weighted temperature and total precipitation. For each location, ENSO exposure (El Nin\u0303o and La Nin\u0303a strength) were calculated by month-specific ENSO indexes and its teleconnection, respectively. A binomial generalized linear mixed-effects model was used to explore the association between ENSO exposure and diarrhea risk in children. Results: Odds ratios of diarrhea in children were 1.032 (95%CI: 1.025, 1.040) and 0.977 (95%CI: 0.971, 0.984) for each standard deviation increase in El Nin\u0303o and La Nin\u0303a strength, respectively. The effect size of El Nin\u0303o was greater for children in rural areas [OR: 1.042 (95%CI: 1.033, 1.052)] and low-income households [OR: 1.047 (95%CI: 1.035, 1.060)]. The association between El Nin\u0303o and diarrhea risk was stronger among those with unimproved toilet facilities and source of drinking water compared to those with improved conditions, while associations were similar by other WASH conditions, and La Nin\u0303a showed similar results in the subgroup analyses. Discussion: This multicountry study indicates an association between ENSO and the diarrhea risk in children under five years globally. Our findings will benefit international prevention and control policy development for diarrhea in children to immediately reduce ENSO-related impacts.<\/jats:p>","DOI":"10.1021\/ehp.6c00005","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T15:02:10Z","timestamp":1789657330000},"page":"613-623","source":"Crossref","is-referenced-by-count":0,"title":["El Nin\u0303o\u2013Southern\nOscillation and Diarrhea\nRisk among Young Children in Low- and Middle-Income Countries"],"prefix":"10.1021","volume":"134","author":[{"given":"Guoao","family":"Li","sequence":"first","affiliation":[{"name":"Shandong University , , , ,","place":["Jinan, Shandong, China, 250012"]},{"name":"Shandong University Climate Change and Health Center , , ,","place":["Jinan, Shandong, China, 250012"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bo","family":"Lu","sequence":"additional","affiliation":[{"name":"China Meteorological Administration , , ,","place":["Beijing, China, 100081"]},{"name":"Xiong\u2019an Institute of Meteorological Artificial Intelligence , , ,","place":["Xiong\u2019an New Area, China, 070001"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mengjie","family":"Geng","sequence":"additional","affiliation":[{"name":"Chinese Center for Disease Control and Prevention , , , ,","place":["Beijing, China, 102206"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haitao","family":"Wang","sequence":"additional","affiliation":[{"name":"Shandong University , , , ,","place":["Jinan, Shandong, China, 250012"]},{"name":"Shandong University Climate Change and Health Center , , ,","place":["Jinan, Shandong, China, 250012"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qi","family":"Zhao","sequence":"additional","affiliation":[{"name":"Shandong University , , , ,","place":["Jinan, Shandong, China, 250012"]},{"name":"Shandong University Climate Change and Health Center , , ,","place":["Jinan, Shandong, China, 250012"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jie","family":"Yan","sequence":"additional","affiliation":[{"name":"Shandong University , , , ,","place":["Jinan, China, 250012"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei","family":"Ma","sequence":"additional","affiliation":[{"name":"Shandong University , , , ,","place":["Jinan, Shandong, China, 250012"]},{"name":"Shandong University Climate Change and Health Center , , ,","place":["Jinan, Shandong, China, 250012"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"316","published-online":{"date-parts":[[2026,9,17]]},"reference":[{"key":"2026101215563606600_cit1","unstructured":"Institute for Health Metrics and Evaluation (IHME).\n          . 2020. Explore results from the 2019 Global Burden of Disease (GBD) study. https:\/\/vizhub.healthdata.org\/gbd-results\/ [Accessed January 16, 2024]."},{"issue":"2","key":"2026101215563606600_cit2","doi-asserted-by":"publisher","first-page":"106","DOI":"10.1016\/S2352-4642(21)00311-4","article-title":"Global, regional, and\nnational causes of under-5 mortality in 2000\u201319: an updated\nsystematic analysis with implications for the Sustainable Development\nGoals","volume":"6","author":"Perin","year":"2022","journal-title":"Lancet Child Adolesc Health"},{"issue":"11","key":"2026101215563606600_cit3","doi-asserted-by":"publisher","first-page":"1211","DOI":"10.1016\/s1473-3099(18)30362-1","article-title":"Estimates of the global, regional, and national morbidity,\nmortality, and aetiologies of diarrhoea in 195 countries: a systematic\nanalysis for the Global Burden of Disease Study 2016","volume":"18","author":"GBD 2016 Diarrhoeal Disease Collaborators.","year":"2018","journal-title":"Lancet Infect Dis"},{"key":"2026101215563606600_cit4","unstructured":"WHO (World Health Organization).\n          . 2024. Diarrhoeal disease. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/diarrhoeal-disease [Accessed January 16, 2024]."},{"issue":"10","key":"2026101215563606600_cit5","doi-asserted-by":"publisher","first-page":"4905","DOI":"10.1021\/acs.est.5b06186","article-title":"Untangling the impacts\nof climate change on waterborne diseases: a systematic review of relationships\nbetween diarrheal diseases and temperature, rainfall, flooding, and\ndrought","volume":"50","author":"Levy","year":"2016","journal-title":"Environ. Sci. Technol."},{"issue":"12","key":"2026101215563606600_cit6","doi-asserted-by":"publisher","first-page":"127002","DOI":"10.1289\/EHP6181","article-title":"Understanding\nthe impact of rainfall on diarrhea: testing\nthe concentration-dilution hypothesis using a systematic review and\nmeta-analysis","volume":"128","author":"Kraay","year":"2020","journal-title":"Environ. Health Perspect"},{"issue":"11","key":"2026101215563606600_cit7","doi-asserted-by":"publisher","first-page":"1206","DOI":"10.1001\/jamapediatrics.2023.3964","article-title":"Floods and\ndiarrhea risk in young children in low- and middle-income countries","volume":"177","author":"Wang","year":"2023","journal-title":"JAMA Pediatr"},{"issue":"1","key":"2026101215563606600_cit8","doi-asserted-by":"publisher","first-page":"3577","DOI":"10.1038\/s41467-022-31291-7","article-title":"Associations\nbetween long-term drought and diarrhea among children under five in\nlow- and middle-income countries","volume":"13","author":"Wang","year":"2022","journal-title":"Nat. Commun."},{"issue":"4","key":"2026101215563606600_cit9","doi-asserted-by":"publisher","first-page":"47004","DOI":"10.1289\/EHP3711","article-title":"Associations\nbetween high temperature, heavy\nrainfall, and diarrhea among young children in rural Tamil Nadu, India:\na prospective cohort study","volume":"127","author":"Mertens","year":"2019","journal-title":"Environ. Health\nPerspect"},{"issue":"5806","key":"2026101215563606600_cit10","doi-asserted-by":"publisher","first-page":"1740","DOI":"10.1126\/science.1132588","article-title":"ENSO as\nan integrating concept in\nEarth science","volume":"314","author":"McPhaden","year":"2006","journal-title":"Science"},{"issue":"3","key":"2026101215563606600_cit11","doi-asserted-by":"publisher","first-page":"325","DOI":"10.1175\/2008BAMS2387.1","article-title":"Understanding El Nin\u0303o in ocean\u2013atmosphere\ngeneral circulation models: Progress and challenges","volume":"90","author":"Guilyardi","year":"2009","journal-title":"Bull. Am. Meteorol Soc."},{"issue":"7715","key":"2026101215563606600_cit12","doi-asserted-by":"publisher","first-page":"535","DOI":"10.1038\/s41586-018-0252-6","article-title":"El Nin\u0303o\u2013Southern Oscillation\ncomplexity","volume":"559","author":"Timmermann","year":"2018","journal-title":"Nature"},{"issue":"2","key":"2026101215563606600_cit13","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1002\/2017RG000568","article-title":"ENSO atmospheric teleconnections\nand their response\nto greenhouse gas forcing","volume":"56","author":"Yeh","year":"2018","journal-title":"Rev. Geophys"},{"key":"2026101215563606600_cit14","unstructured":"WHO.\n          . 2023. El Nin\u0303o Southern Oscillation\n(ENSO). https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/el-nino-southern-oscillation-(enso) [Accessed October 20, 2024]."},{"key":"2026101215563606600_cit15","doi-asserted-by":"publisher","first-page":"14451","DOI":"10.1029\/97JC02719","article-title":"Monsoons: processes, predictability, and the prospects\nfor prediction","volume":"103","author":"Webster","year":"1998","journal-title":"J. Geophys Res."},{"issue":"1","key":"2026101215563606600_cit16","doi-asserted-by":"publisher","first-page":"5798","DOI":"10.1038\/s41467-019-13584-6","article-title":"El Nin\u0303o-Southern\nOscillation\nand under-5 diarrhea in Botswana","volume":"10","author":"Heaney","year":"2019","journal-title":"Nat. Commun."},{"issue":"7","key":"2026101215563606600_cit17","doi-asserted-by":"publisher","first-page":"e63","DOI":"10.2105\/AJPH.2011.300573","article-title":"Effects of the 1997\u20131998\nEl Nin\u0303o episode\non community rates of diarrhea","volume":"102","author":"Bennett","year":"2012","journal-title":"Am. J. Public\nHealth"},{"issue":"6649","key":"2026101215563606600_cit18","doi-asserted-by":"publisher","first-page":"1064","DOI":"10.1126\/science.adf2983","article-title":"Persistent effect\nof El Nin\u0303o on global economic\ngrowth","volume":"380","author":"Callahan","year":"2023","journal-title":"Science"},{"key":"2026101215563606600_cit19","doi-asserted-by":"publisher","DOI":"10.13140\/RG.2.1.4887.6563","article-title":"Geographic Displacement\nProcedure and Georeferenced Data Release Policy for the Demographic\nand Health Surveys","author":"Burgert","year":"2013","journal-title":"Demographic and Health Surveys"},{"key":"2026101215563606600_cit20","unstructured":"Rutstein, S. O., Johnson, K.\n          2004. The DHS wealth index.  DHS Comparative Reports\nNo. 6. ORC Macro: Calverton, Maryland, USA, http:\/\/dhsprogram.com\/pubs\/pdf\/CR6\/CR6.pdf."},{"issue":"D14","key":"2026101215563606600_cit21","doi-asserted-by":"publisher","DOI":"10.1029\/2002JD002670","article-title":"Global analyses\nof sea surface temperature, sea\nice, and night marine air temperature since the late nineteenth century","volume":"108","author":"Rayner","year":"2003","journal-title":"J. Geophys Res-Atmos"},{"key":"2026101215563606600_cit22","doi-asserted-by":"publisher","DOI":"10.24381\/cds.adbb2d47","article-title":"ERA5 hourly\ndata on single levels from 1940 to present","author":"Hersbach","year":"2023","journal-title":"Copernicus Climate Change Service (C3S) Climate Data Store\n(CDS)"},{"issue":"7735","key":"2026101215563606600_cit23","doi-asserted-by":"publisher","first-page":"201","DOI":"10.1038\/s41586-018-0776-9","article-title":"Increased variability of eastern Pacific El\nNin\u0303o under greenhouse warming","volume":"564","author":"Cai","year":"2018","journal-title":"Nature"},{"issue":"1","key":"2026101215563606600_cit24","doi-asserted-by":"publisher","first-page":"6616","DOI":"10.1038\/s41467-022-33930-5","article-title":"Emergence\nof changing Central-Pacific and Eastern-Pacific El Nin\u0303o-Southern\nOscillation in a warming climate","volume":"13","author":"Geng","year":"2022","journal-title":"Nat. Commun."},{"issue":"7823","key":"2026101215563606600_cit25","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1038\/s41586-020-2641-x","article-title":"Butterfly\neffect and a self-modulating El Nin\u0303o response to global warming","volume":"585","author":"Cai","year":"2020","journal-title":"Nature"},{"key":"2026101215563606600_cit26","doi-asserted-by":"publisher","first-page":"L10704","DOI":"10.1029\/2011GL047364","article-title":"ENSO regimes: Reinterpreting\nthe canonical and Modoki El Nin\u0303o","volume":"38","author":"Takahashi","year":"2011","journal-title":"Geophys.\nRes. Lett."},{"key":"2026101215563606600_cit27","unstructured":"Brannick, M.\n          \n          Partial and semipartial\ncorrelation. http:\/\/faculty.cas.usf.edu\/mbrannick\/regression\/Partial.html [accessed 18 October 2024]. Lecture Notes, 1997; Vol. 8, p 13710.1016\/S0955-1662(97)00043-X."},{"key":"2026101215563606600_cit28","doi-asserted-by":"crossref","unstructured":"Fantom, N. 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Macro International, Calverton, Maryland, USA. http:\/\/dhsprogram.com\/pubs\/pdf\/WP60\/WP60.pdf."},{"issue":"7382","key":"2026101215563606600_cit31","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1136\/bmj.326.7382.219","article-title":"Interaction revisited:\nthe difference between two estimates","volume":"326","author":"Altman","year":"2003","journal-title":"BMJ."},{"issue":"11","key":"2026101215563606600_cit32","doi-asserted-by":"publisher","first-page":"4015","DOI":"10.1175\/JCLI-D-13-00130.1","article-title":"The varied impacts\nof El Nin\u0303o-Southern\nOscillation on Pacific island climates","volume":"27","author":"Murphy","year":"2014","journal-title":"J. Climate"},{"issue":"1","key":"2026101215563606600_cit33","doi-asserted-by":"publisher","first-page":"214","DOI":"10.4269\/ajtmh.2005.73.214","article-title":"Use of rainfall\nand sea surface temperature monitoring for malaria early warning in\nBotswana","volume":"73","author":"Thomson","year":"2005","journal-title":"Am. J. Trop Med. Hyg"},{"issue":"7076","key":"2026101215563606600_cit34","doi-asserted-by":"publisher","first-page":"576","DOI":"10.1038\/nature04503","article-title":"Malaria early warnings\nbased on seasonal climate\nforecasts from multi-model ensembles","volume":"439","author":"Thomson","year":"2006","journal-title":"Nature"},{"issue":"9394","key":"2026101215563606600_cit35","doi-asserted-by":"publisher","first-page":"1481","DOI":"10.1016\/S0140-6736(03)14695-8","article-title":"El Nin\u0303o\nand health","volume":"362","author":"Kovats","year":"2003","journal-title":"Lancet"},{"issue":"2","key":"2026101215563606600_cit36","doi-asserted-by":"publisher","first-page":"451","DOI":"10.1111\/gcb.16466","article-title":"Effects of El Nin\u0303o drought\non seedling dynamics in a seasonally\ndry tropical forest in Northern Thailand","volume":"29","author":"Nutiprapun","year":"2023","journal-title":"Global\nChange Biol."},{"issue":"6145","key":"2026101215563606600_cit37","doi-asserted-by":"publisher","first-page":"508","DOI":"10.1126\/science.1239402","article-title":"Climate change\nimpacts on global food security","volume":"341","author":"Wheeler","year":"2013","journal-title":"Science"},{"issue":"6145","key":"2026101215563606600_cit38","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1126\/science.1239401","article-title":"Climate\nchange and infectious diseases: From evidence to a predictive framework","volume":"341","author":"Altizer","year":"2013","journal-title":"Science"},{"issue":"3","key":"2026101215563606600_cit39","doi-asserted-by":"publisher","first-page":"E373","DOI":"10.1016\/S2214-109X(22)00549-6","article-title":"Spatiotemporal\nvariation in risk of Shigella infection\nin childhood: A global risk mapping and prediction model using individual\nparticipant data","volume":"11","author":"Badr","year":"2023","journal-title":"Lancet Glob Health"},{"issue":"2","key":"2026101215563606600_cit40","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1016\/S1286-4579(00)00272-0","article-title":"Temperature-regulated\nexpression of bacterial virulence genes","volume":"2","author":"Konkel","year":"2000","journal-title":"Microbes\nInfect"},{"key":"2026101215563606600_cit41","doi-asserted-by":"publisher","first-page":"116607","DOI":"10.1016\/j.watres.2020.116607","article-title":"Household practices\nin accessing drinking water and post collection contamination: A seasonal\ncohort study in Malawi","volume":"189","author":"Cassivi","year":"2021","journal-title":"Water Res."},{"issue":"16","key":"2026101215563606600_cit42","doi-asserted-by":"publisher","first-page":"6465","DOI":"10.1021\/acs.est.2c09344","article-title":"Drinking water in rural China: water sources, treatment,\nand boiling energy","volume":"57","author":"Zhu","year":"2023","journal-title":"Environ. Sci. Technol."},{"key":"2026101215563606600_cit43","doi-asserted-by":"publisher","first-page":"S109","DOI":"10.2105\/AJPH.2011.300189","article-title":"Drinking water\ninfrastructure and environmental disparities: evidence and methodological\nconsiderations","volume":"101","author":"VanDerslice","year":"2011","journal-title":"Am. J. Public Health"},{"issue":"7","key":"2026101215563606600_cit44","doi-asserted-by":"publisher","first-page":"282","DOI":"10.3390\/atmos9070282","article-title":"El Nin\u0303o Southern Oscillation\n(ENSO) and health: an overview\nfor climate and health researchers","volume":"9","author":"McGregor","year":"2018","journal-title":"Atmosphere"},{"issue":"1","key":"2026101215563606600_cit45","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1073\/pnas.1917007117","article-title":"Complexity-based\napproach for El Nin\u0303o magnitude forecasting\nbefore the spring predictability barrier","volume":"117","author":"Meng","year":"2020","journal-title":"Proc.\nNatl. Acad. Sci. U. S. 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