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Author Notes:

E-mail address: kelly-k-baker@uiowa.edu

Conceived and designed the experiments: MML KLK JPN KKB CEO EDM.

Analyzed the data: KKB CEO TLA EDM.

Wrote the first draft of the manuscript: KKB.

Contributed to the writing of the manuscript: KKB CEO TLA EDM.

Agree with the manuscript’s results and conclusions: KKB CEO MML KLK JPN TLA THF DN WCB YW PLA RFB RO ASGF SKD SA DSa SOS DSu AKMZ FQ EDM.

Supervised enrollment of patients, implementation of the study protocol, and data acquisition: PLA RFB RO ASGF SKD SA DSa SOS DSu AKMZ FQ.

Epidemiology Study Coordinators: THF DN.

Provided biostatistical support for the study: TLA WCB YW.

We are grateful to the global village of clinical, laboratory, field, data management, and administrative staff at the seven GEMS sites and the multiple supporting institutions who made this work possible.

The authors have declared that no competing interests exist.


Research Funding:

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.


  • Sanitation
  • Hygiene
  • Diarrhea
  • Children
  • Defecation
  • Hands
  • Surface water
  • Water resources

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

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Journal Title:

PLoS Medicine


Volume 13, Number 5


, Pages e1002010-e1002010

Type of Work:

Article | Final Publisher PDF


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.

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This is an Open Access work distributed under the terms of the Creative Commons Universal : Public Domain Dedication License (http://creativecommons.org/publicdomain/zero/1.0/).

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