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

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 youn...

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Published in:	PLoS medicine Vol. 13; no. 5; p. e1002010
Main Authors:	Baker, Kelly K, O'Reilly, Ciara E, Levine, Myron M, Kotloff, Karen L, Nataro, James P, Ayers, Tracy L, Farag, Tamer H, Nasrin, Dilruba, Blackwelder, William C, Wu, Yukun, Alonso, Pedro L, Breiman, Robert F, Omore, Richard, Faruque, Abu S G, Das, Sumon Kumar, Ahmed, Shahnawaz, Saha, Debasish, Sow, Samba O, Sur, Dipika, Zaidi, Anita K M, Quadri, Fahreen, Mintz, Eric D
Format:	Journal Article
Language:	English
Published:	United States Public Library of Science 03-05-2016 Public Library of Science (PLoS)
Subjects:	Africa - epidemiology Asia - epidemiology Biology and Life Sciences Case-Control Studies Child, Preschool Children Diarrea Diarrhea Diarrhea - epidemiology Diarrhea - etiology Earth Sciences Ecology and Environmental Sciences Female Health aspects Health risk assessment Higiene Households Humans Hygiene Infant Infant, Newborn Infants Male Medicine and Health Sciences People and Places Risk Factors Sanitation - statistics & numerical data Studies United States Mozambique Spain Bangladesh Pakistan Mali Africa Kenya India South Asia
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Summary:	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. 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. 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.
Bibliography:	The authors have declared that no competing interests exist. 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. All authors have read, and confirm that they meet, ICMJE criteria for authorship.
ISSN:	1549-1676 1549-1277 1549-1676
DOI:	10.1371/journal.pmed.1002010