Safe child feces management (CFM) is likely critical for reducing exposure to fecal pathogens in and around the home, but the effectiveness of different CFM practices in reducing fecal contamination is not well understood. We conducted a cross-sectional study of households with children <6 years in rural Odisha, India, using household surveys (188 households), environmental sample analysis (373 samples for 80 child defecation events), and unstructured observation (33 households) to characterize practices and measure fecal contamination resulting from CFM-related practices, including defecation, feces handling and disposal, defecation area or tool cleaning, anal cleansing, and handwashing. For environmental sampling, we developed a sampling strategy that involved collecting samples at the time and place of child defecation to capture activity-level fecal contamination for CFM practices. Defecating on the floor or ground, which was practiced by 63.7% of children <6 years, was found to increase E. coli contamination on finished floors (p < 0.001) or earthen ground surfaces (p = 0.008) after feces were removed, even if paper was laid down prior to defecation. Use of unsafe tools (e.g., paper, plastic bag, straw/hay) to pick up child feces increased E. coli contamination on caregiver hands after feces handling (p < 0.0001), whereas the use of safe tools (e.g., potty, hoe, scoop) did not increase hand contamination. Points of contamination from cleaning CFM hardware and anal cleansing were also identified. The most common disposal location for feces of children <6 years was to throw feces into an open field (41.6%), with only 32.3% disposed in a latrine. Several households owned scoops or potties, but use was low and we identified shortcomings of these CFM tools and proposed alternative interventions that may be more effective. Overall, our results demonstrate the need for CFM interventions that move beyond focusing solely on feces disposal to address CFM as a holistic set of practices.

Child feces represent a particular health risk to children due to increased prevalence of enteric agents and a higher risk of exposure owing to exploratory behaviors of young children. The safe management of such feces presents a significant challenge, not only for the 2.4 billion who lack access to improved sanitation, but also due to unhygienic feces collection and disposal and poor subsequent h and washing practices. We assessed potential sources of fecal exposure by documenting child feces management practices in a cross-sectional study of 851 children < 5 years of age from 694 households in 42 slums in two cities in Odisha, India. No preambulatory children and only 27.4% of ambulatory children defecated directly in the latrine. Children that did not defecate in a latrine mainly defecated on the ground, whether they were preambulatory or ambulatory. Use of diapers (1.2%) or potties (2.8%) was low. If the feces were removed from the ground, the defecation area was usually cleaned, if at all, only with water. Most children's feces were disposed of in surrounding environment, with only 6.5% deposited into any kind of latrine, including unimproved. Handwashing with soap of the caregiver after child feces disposal and child anal cleaning with soap after defecation was also uncommon. While proper disposal of child feces in an improved latrine still represents a major challenge, control of the risks presented requires attention to the full range of exposures associated to the management of child feces, and not simply the place of disposal.