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

• Type of Material: Article
• Authors: Kelly K. Baker, University of Maryland; Ciara O'Reilly, Emory University; Myron M. Levine, University of Maryland; Karen L. Kotloff, University of Maryland; James P. Nataro, University of Maryland; Tracy L. Ayers, Centers for Disease Control and Prevention; Tamer H. Farag, University of Maryland; Dilruba Nasrin, University of Maryland; William C. Blackwelder, University of Maryland; Yukun Wu, University of Maryland; Pedro L. Alonso, University of Barcelona; Robert Breiman, Emory University; Richard Omore, Kenya Medical Research Institute/Centers for Disease Control and Prevention (KEMRI/CDC); Abu S.G. Faruque, International Centre for Diarrhoeal Disease Research; Sumon Kumar Das, International Centre for Diarrhoeal Disease Research; Shahnawaz Ahmed, International Centre for Diarrhoeal Disease Research; Debasish Saha, Medical Research Council (United Kingdom); Samba O. Sow, Centre pour le Développement des Vaccins, Mali; Dipika Sur, National Institute of Cholera and Enteric Diseases, India; Anita K.M. Zaidi, Gates Foundation; Fahreen Quadri, Aga Khan University; Eric Mintz, Emory University
• Language: English
• Date: 2016-05-01
• Publisher: Public Library of Science
• Publication Version: Final Published Version
• Copyright Statement: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose.
• License: Creative Commons Creative Commons CC0 1.0 Universal
• Final Published Version (URL): http://dx.doi.org/10.1371/journal.pmed.1002010
• Title of Journal or Parent Work: PLoS Medicine
• ISSN: 1549-1277
• Volume: 13
• Issue: 5
• Start Page: e1002010
• End Page: e1002010
• Grant/Funding Information: This work was supported by Grant #38874 from the Bill and Melinda Gates Foundation to MML, Principal Investigator.; Salary support for CEO was provided by the US Agency for International Development through an Inter-Agency Agreement with the US Centers for Disease Control and Prevention.
• Keywords: Children; CHOLERA OUTBREAK; Defecation; SHARED SANITATION; GAMBIAN INFANTS; KAMPALA SLUMS; Water resources; Sanitation; HOUSEHOLD LATRINES; DEVELOPING-COUNTRIES; MORTALITY; Hygiene; Hands; SYSTEMATIC ANALYSIS; NATIONAL CAUSES; Diarrhea; Surface water
• Research Categories: Health Sciences, Public Health; Health Sciences, Hygiene; Health Sciences, Epidemiology

Abstract

Background: Diarrheal 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/Findings: The 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. Conclusions: This 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.