Household sanitation is associated with lower risk of bacterial and protozoal enteric infections, but not viral infections and diarrhoea, in a cohort study in a low-income urban neighbourhood in Vellore, India

• Authors: David Berendes, Georgia Institute of Technology; Juan Leon, Emory University; Amy Kirby, Emory University; Julie Clennon, Emory University; Suraja Raj, Emory University; Habib Yakubu, Emory University; Katharine Robb, Emory University; Arun Kartikeyan, Christian Medical College; Priya Hemavathy, Christian Medical College; Annai Gunasekaran, Christian Medical College; Sheela Roy, Christian Medical College; Ben Chirag Ghale, Christian Medical College; J. Senthil Kumar, Christian Medical College; Venkata Raghava Mohan, Christian Medical College; Gagandeep Kang, Christian Medical College; Christine Moe, Emory University
• Journal Title: Tropical Medicine and International Health
• Volume: Volume 22, Number 9
• Publisher: Wiley | 2017-09-01, Pages 1119-1129
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1111/tmi.12915
• Subjects: Health Sciences, Public Health; Biology, Biostatistics
• Keywords: Science & Technology; Life Sciences & Biomedicine; Public, Environmental & Occupational Health; Tropical Medicine; sanitation; enteric infection; India; epidemiology; children; diarrhoea; MAL-ED COHORT; FECAL SLUDGE MANAGEMENT; OPTIMAL RECALL PERIOD; CHILDHOOD DIARRHEA; ENVIRONMENTAL-CONDITIONS; DEVELOPING-COUNTRIES; CONTROLLED-TRIALS; NORWALK VIRUS; BIRTH COHORT; IMPACT

Abstract

Objective: This study examined associations between household sanitation and enteric infection – including diarrhoeal-specific outcomes – in children 0–2 years of age in a low-income, dense urban neighbourhood. Methods: As part of the MAL-ED study, 230 children in a low-income, urban, Indian neighbourhood provided stool specimens at 14–17 scheduled time points and during diarrhoeal episodes in the first 2 years of life that were analysed for bacterial, parasitic (protozoa and helminths) and viral pathogens. From interviews with caregivers in 100 households, the relationship between the presence (and discharge) of household sanitation facilities and any, pathogen-specific, and diarrhoea-specific enteric infection was tested through mixed-effects Poisson regression models. Results: Few study households (33%) reported having toilets, most of which (82%) discharged into open drains. Controlling for season and household socio-economic status, the presence of a household toilet was associated with lower risks of enteric infection (RR: 0.91, 95% CI: 0.79–1.06), bacterial infection (RR: 0.87, 95% CI: 0.75–1.02) and protozoal infection (RR: 0.64, 95% CI: 0.39–1.04), although not statistically significant, but had no association with diarrhoea (RR: 1.00, 95% CI: 0.68–1.45) or viral infections (RR: 1.12, 95% CI: 0.79–1.60). Models also suggested that the relationship between household toilets discharging to drains and enteric infection risk may vary by season. Conclusions: The presence of a household toilet was associated with lower risk of bacterial and protozoal enteric infections, but not diarrhoea or viral infections, suggesting the health effects of sanitation may be more accurately estimated using outcome measures that account for aetiologic agents.