Abstract
Diarrheal disease remains a major cause of childhood mortality and morbidity causing poor health and economic outcomes. In low-resource settings, young children are exposed to numerous risk factors for enteric pathogen transmission within their dwellings, though the relative importance of different transmission pathways varies by pathogen species. The objective of this analysis was to model associations between five household-level risk factors—water, sanitation, flooring, caregiver education, and crowding—and infection status for endemic enteric pathogens in children in five surveillance studies. Data were combined from 22 sites in which a total of 58,000 stool samples were tested for 16 specific enteropathogens using qPCR. Risk ratios for pathogen- and taxon-specific infection status were modeled using generalized linear models along with hazard ratios for all-cause diarrhea in proportional hazard models, with the five household-level variables as primary exposures adjusting for covariates. Improved drinking water sources conferred a 17% reduction in diarrhea risk; however, the direction of its association with particular pathogens was inconsistent. Improved sanitation was associated with a 9% reduction in diarrhea risk with protective effects across pathogen species and taxa of around 10–20% risk reduction. A 9% reduction in diarrhea risk was observed in subjects with covered floors, which were also associated with decreases in risk for zoonotic enteropathogens. Caregiver education and household crowding showed more modest, inconclusive results. Combining data from diverse sites, this analysis quantified associations between five household-level exposures on risk of specific enteric infections, effects which differed by pathogen species but were broadly consistent with hypothesized transmission mechanisms. Such estimates may be used within expanded water, sanitation, and hygiene (WASH) programs to target interventions to the particular pathogen profiles of individual communities and prioritize resources.
Highlights
Despite considerable progress in recent years, diarrheal disease remains a major cause of mortality and morbidity in childhood [1,2]—responsible for some 446,000 under-five deaths in 2016 [3]—and its sequelae lead to poor health and economic outcomes in adulthood [4,5]
For all pathogen-specific associations, modified Poisson regression models were fitted to the binary outcome in the full database using generalized linear models with cluster-robust variance estimation to calculate adjusted risk ratios (RRs) for infection for each of the five risk factors in the presence of each other and the potential confounders [37]
This was illustrated in recently published results from the SHINE trial, which showed a statistically significant decrease in parasite detections following water, sanitation, and hygiene (WASH) interventions [29] in the absence of any commensurate detectable decrease in caregiver-reported diarrhea [40]
Summary
Despite considerable progress in recent years, diarrheal disease remains a major cause of mortality and morbidity in childhood [1,2]—responsible for some 446,000 under-five deaths in 2016 [3]—and its sequelae lead to poor health and economic outcomes in adulthood [4,5]. Inadequate sanitation and drinking water are leading household-level risk factors for all-cause childhood diarrhea but, while systematic reviews have estimated that improvements to these facilities can reduce the risk of this outcome by between 25% and 75% [13,14], three high-profile randomized control trials found more mixed, context-dependent effects [15]. They likely do not impact transmission of rotavirus [16], one of the pathogens responsible for the largest share of the diarrheal disease burden [2,17,18]. The link between a mother’s level of education and the health, nutrition, and mortality prospects of her offspring is credited with having averted 4.2 million child deaths between
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