Abstract
Enteric pathogens can be transmitted through multiple environmental pathways, yet little is known about the relative contribution of each pathway to diarrhea risk among children. We aimed to identify fecal transmission pathways in the household environment associated with prospectively measured child diarrhea in rural Bangladesh. We measured the presence and levels of Escherichia coli in tube wells, stored drinking water, pond water, child hand rinses, courtyard soil, flies, and food in 1843 households. Gastrointestinal symptoms among children ages 0–60 months were recorded concurrently at the time of environmental sample collection and again a median of 6 days later. Incident diarrhea (3 or more loose stools in a 24-h period) was positively associated with the concentration of E. coli on child hands measured on the first visit (incidence rate ratio [IRR] = 1.23, 95% CI 1.06, 1.43 for a log10 increase), while other pathways were not associated. In cross-sectional analysis, there were no associations between concurrently measured environmental contamination and diarrhea. Our findings suggest higher levels of E. coli on child hands are strongly associated with subsequent diarrheal illness rates among children in rural Bangladesh.
Highlights
Diarrhea is a leading cause of global mortality, causing over 1 million deaths in the year 2016.1 The morbidity burden of diarrhea is substantial: in 2010 there were an estimated 1.7 billion episodes of diarrhea.[2]
We examined how a prospective analysis with incident episodes measured after exposure compared with cross-sectional analysis of environmental fecal contamination and concurrently measured diarrhea prevalence
To compare our prospective analysis with a cross-sectional analysis approach, we repeated the analyses described above using 7-day prevalence of diarrhea measured at the first household visit as the dependent variable; this analysis used illness prevalence as the outcome measure as incident diarrhea or blood in stool episodes could not be identified at the first household visit without prior knowledge of symptom
Summary
Diarrhea is a leading cause of global mortality, causing over 1 million deaths in the year 2016.1 The morbidity burden of diarrhea is substantial: in 2010 there were an estimated 1.7 billion episodes of diarrhea.[2]. Most previous studies have used cross-sectional associations between levels of fecal contamination in the environment and concurrent diarrhea prevalence. The association between fecal contamination levels in stored drinking water and concurrent diarrhea has been extensively studied, with equivocal results.[9,10] One study in Tanzania found that levels of hand fecal contamination was a stronger predictor of concurrent diarrheal illness within a household than fecal contamination levels in stored drinking water.[11]
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