Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007–2011: Case-Control Study

Abstract

BackgroundDiarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child's risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age.Methods/FindingsThe GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1–2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India.ConclusionsThis study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children's Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.

Does Measles Vaccination Reduce the Risk of Acute Respiratory Infection (ARI) and Diarrhea in Children: A Multi-Country Study?

“…Households’ access to improved toilet facilities decreased the risk of diarrhea in children in the Democratic Republic of Congo. These findings are consistent with several past studies on this subject [35,45–48]. Age and birth size of child, mother’s literacy, religion and household wealth were statistically associated with ARI and diarrhea in children.…”

Enteroaggregative Escherichia coli is the predominant diarrheagenic E. coli pathotype among irrigation water and food sources in South Africa

“…South Africa like many developing and Sub-Saharan African countries experiences a high incidence of diarrhoea (Tau et al, 2012) in infants and immune compromised adults, such as HIV-positive patients (Samie et al, 2007). Such illness would disproportionately affect the low income population, which makes up a large part of the urban and rural population (World Bank, 2014) due to inadequate waste disposal and sanitation facilities (Baker et al, 2016). Within South Africa, The National Institute of Communicable Diseases (NICD) initiated a national surveillance program to monitor diarrheagenic pathotypes (Tau et al, 2012).…”

Cities, slums, and child nutrition in Bangladesh

“…Baker et al. () find that young children in households that share toilet facilities have a significantly higher rate of diarrhea in Mirzapur city (as well as in selected urban centers in Africa and other South Asian countries).…”

“…Lin et al (2013) find that sanitary household WASH conditions are significantly associated with a lower rate of intestinal parasitic infection, better nutrition status, and lower rates of markers of environmental enteropathy among young children in a sample of rural households. Baker et al (2016) find that young children in households that share toilet facilities have a significantly higher rate of diarrhea in Mirzapur city (as well as in selected urban centers in Africa and other South Asian countries).…”